PDF(Pubmed)
Abstract：
Clinical guidelines for patients with heart failure with reduced ejection fraction (HFrEF) strongly recommend treatment with a sodium-glucose cotransporter-2 inhibitor (SGLT2i) to reduce cardiovascular mortality or HF hospitalization. Nationwide adoption of SGLT2i for HFrEF in the US is unknown.
To characterize patterns of SGLT2i use among eligible US patients hospitalized for HFrEF.
This retrospective cohort study analyzed 49 399 patients hospitalized for HFrEF across 489 sites in the Get With The Guidelines-Heart Failure (GWTG-HF) registry between July 1, 2021, and June 30, 2022. Patients with an estimated glomerular filtration rate less than 20 mL/min/1.73 m2, type 1 diabetes, and previous intolerance to SGLT2i were excluded.
Patient-level and hospital-level prescription of SGLT2i at hospital discharge.
Of 49 399 included patients, 16 548 (33.5%) were female, and the median (IQR) age was 67 (56-78) years. Overall, 9988 patients (20.2%) were prescribed an SGLT2i. SGLT2i prescription was less likely among patients with chronic kidney disease (CKD; 4550 of 24 437 [18.6%] vs 5438 of 24 962 [21.8%]; P < .001) but more likely among patients with type 2 diabetes (T2D; 5721 of 21 830 [26.2%] vs 4262 of 27 545 [15.5%]; P < .001) and those with both T2D and CKD (2905 of 12 236 [23.7%] vs 7078 vs 37 139 [19.1%]; P < .001). Patients prescribed SGLT2i therapy were more likely to be prescribed background triple therapy with an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, β-blocker, and mineralocorticoid receptor antagonist (4624 of 9988 [46.3%] vs 10 880 of 39 411 [27.6%]; P < .001), and 4624 of 49 399 total study patients (9.4%) were discharged with prescriptions for quadruple medical therapy including SGLT2i. Among 461 hospitals with 10 or more eligible discharges, 19 hospitals (4.1%) discharged 50% or more of patients with prescriptions for SGLT2i, whereas 344 hospitals (74.6%) discharged less than 25% of patients with prescriptions for SGLT2i (including 29 [6.3%] that discharged zero patients with SGLT2i prescriptions). There was high between-hospital variance in the rate of SGLT2i prescription in unadjusted models (median odds ratio, 2.53; 95% CI, 2.36-2.74) and after adjustment for patient and hospital characteristics (median odds ratio, 2.51; 95% CI, 2.34-2.71).
In this study, prescription of SGLT2i at hospital discharge among eligible patients with HFrEF was low, including among patients with comorbid CKD and T2D who have multiple indications for therapy, with substantial variation among US hospitals. Further efforts are needed to overcome implementation barriers and improve use of SGLT2i among patients with HFrEF.
To characterize patterns of SGLT2i use among eligible US patients hospitalized for HFrEF.
This retrospective cohort study analyzed 49 399 patients hospitalized for HFrEF across 489 sites in the Get With The Guidelines-Heart Failure (GWTG-HF) registry between July 1, 2021, and June 30, 2022. Patients with an estimated glomerular filtration rate less than 20 mL/min/1.73 m2, type 1 diabetes, and previous intolerance to SGLT2i were excluded.
Patient-level and hospital-level prescription of SGLT2i at hospital discharge.
Of 49 399 included patients, 16 548 (33.5%) were female, and the median (IQR) age was 67 (56-78) years. Overall, 9988 patients (20.2%) were prescribed an SGLT2i. SGLT2i prescription was less likely among patients with chronic kidney disease (CKD; 4550 of 24 437 [18.6%] vs 5438 of 24 962 [21.8%]; P < .001) but more likely among patients with type 2 diabetes (T2D; 5721 of 21 830 [26.2%] vs 4262 of 27 545 [15.5%]; P < .001) and those with both T2D and CKD (2905 of 12 236 [23.7%] vs 7078 vs 37 139 [19.1%]; P < .001). Patients prescribed SGLT2i therapy were more likely to be prescribed background triple therapy with an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, β-blocker, and mineralocorticoid receptor antagonist (4624 of 9988 [46.3%] vs 10 880 of 39 411 [27.6%]; P < .001), and 4624 of 49 399 total study patients (9.4%) were discharged with prescriptions for quadruple medical therapy including SGLT2i. Among 461 hospitals with 10 or more eligible discharges, 19 hospitals (4.1%) discharged 50% or more of patients with prescriptions for SGLT2i, whereas 344 hospitals (74.6%) discharged less than 25% of patients with prescriptions for SGLT2i (including 29 [6.3%] that discharged zero patients with SGLT2i prescriptions). There was high between-hospital variance in the rate of SGLT2i prescription in unadjusted models (median odds ratio, 2.53; 95% CI, 2.36-2.74) and after adjustment for patient and hospital characteristics (median odds ratio, 2.51; 95% CI, 2.34-2.71).
In this study, prescription of SGLT2i at hospital discharge among eligible patients with HFrEF was low, including among patients with comorbid CKD and T2D who have multiple indications for therapy, with substantial variation among US hospitals. Further efforts are needed to overcome implementation barriers and improve use of SGLT2i among patients with HFrEF.
摘要：
■射血分数降低（HFrEF）的心力衰竭患者的临床指南强烈建议使用钠-葡萄糖协同转运蛋白-2抑制剂（SGLT2i）治疗以降低心血管死亡率或HF住院。在美国，在全国范围内采用SGLT2i用于HFrEF是未知的。
■描述因HFrEF住院的合格美国患者中SGLT2i的使用模式。
这项回顾性队列研究分析了2021年7月1日至2022年6月30日在GetWithTheGuidelines-HeartFailure（GWTG-HF）注册的489个地点因HFrEF住院的49399例患者。估计肾小球滤过率小于20mL/min/1.73m2，1型糖尿病患者，和以前对SGLT2i的不耐受被排除。
■出院时SGLT2i的患者级和医院级处方。
■在49399名患者中，16548（33.5％）为女性，中位年龄（IQR）为67（56-78）岁。总的来说,9988名患者（20.2%）服用SGLT2i。SGLT2i处方在慢性肾脏病患者中的可能性较小（CKD；24437中的4550[18.6％]vs24962中的5438[21.8％]；P<.001），但在2型糖尿病患者中的可能性更大（T2D；21830中的5721[26.2％]vs27545中的4262[15.5％]；P<.001）以及T2D和使用SGLT2i治疗的患者更有可能使用血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂/血管紧张素受体-脑啡肽酶抑制剂进行背景三联疗法，β-受体阻滞剂,和盐皮质激素受体拮抗剂（9988的4624[46.3％]vs39411的10880[27.6％]；P<.001），49399名总研究患者中的4624名(9.4%)出院，接受包括SGLT2i在内的四联药物治疗。在有10家或以上合格出院的461家医院中，19家医院(4.1%)出院50%或更多的患者服用SGLT2i处方，而344家医院(74.6%)的SGLT2i处方患者出院比例低于25%(包括29家[6.3%]的SGLT2i处方患者出院比例为零).在未调整的模型中，SGLT2i处方率的医院间差异很高(中位数比值比，2.53；95%CI，2.36-2.74)和调整患者和医院特征后(中位比值比，2.51；95%CI，2.34-2.71）。
■在这项研究中，合格的HFrEF患者出院时SGLT2i的处方较低，包括有多种治疗指征的CKD和T2D合并症患者，美国医院之间存在很大差异。需要进一步努力克服实施障碍并改善HFrEF患者中SGLT2i的使用。
■描述因HFrEF住院的合格美国患者中SGLT2i的使用模式。
这项回顾性队列研究分析了2021年7月1日至2022年6月30日在GetWithTheGuidelines-HeartFailure（GWTG-HF）注册的489个地点因HFrEF住院的49399例患者。估计肾小球滤过率小于20mL/min/1.73m2，1型糖尿病患者，和以前对SGLT2i的不耐受被排除。
■出院时SGLT2i的患者级和医院级处方。
■在49399名患者中，16548（33.5％）为女性，中位年龄（IQR）为67（56-78）岁。总的来说,9988名患者（20.2%）服用SGLT2i。SGLT2i处方在慢性肾脏病患者中的可能性较小（CKD；24437中的4550[18.6％]vs24962中的5438[21.8％]；P<.001），但在2型糖尿病患者中的可能性更大（T2D；21830中的5721[26.2％]vs27545中的4262[15.5％]；P<.001）以及T2D和使用SGLT2i治疗的患者更有可能使用血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂/血管紧张素受体-脑啡肽酶抑制剂进行背景三联疗法，β-受体阻滞剂,和盐皮质激素受体拮抗剂（9988的4624[46.3％]vs39411的10880[27.6％]；P<.001），49399名总研究患者中的4624名(9.4%)出院，接受包括SGLT2i在内的四联药物治疗。在有10家或以上合格出院的461家医院中，19家医院(4.1%)出院50%或更多的患者服用SGLT2i处方，而344家医院(74.6%)的SGLT2i处方患者出院比例低于25%(包括29家[6.3%]的SGLT2i处方患者出院比例为零).在未调整的模型中，SGLT2i处方率的医院间差异很高(中位数比值比，2.53；95%CI，2.36-2.74)和调整患者和医院特征后(中位比值比，2.51；95%CI，2.34-2.71）。
■在这项研究中，合格的HFrEF患者出院时SGLT2i的处方较低，包括有多种治疗指征的CKD和T2D合并症患者，美国医院之间存在很大差异。需要进一步努力克服实施障碍并改善HFrEF患者中SGLT2i的使用。
