目的:一半的心力衰竭(HF)患者患有慢性肾脏病(CKD),使其药物治疗复杂化。我们评估了医生和患者在不同CKD阶段的HF中使用循证医学疗法的模式。
结果:我们研究了2009-2018年瑞典心力衰竭登记处的心力衰竭患者射血分数降低(HFrEF)和轻度降低(HFmrEF)。我们调查了医生为CKD患者开具指南推荐疗法的可能性,以及在发生HF(开始治疗)后90天内填写处方的患者,在治疗的第一年坚持(覆盖天数比例≥80%)和坚持(继续使用)这些治疗。我们确定了31668例HFrEF患者(中位年龄74岁,46%CKD)。接受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-脑啡肽抑制剂(ACEi/ARB/ARNi)处方的比例为96%,92%,86%,68%,对于估计的肾小球滤过率(eGFR)≥60、45-59、30-44和<30ml/min/1.73m2,分别为94%的β受体阻滞剂,93%,92%,92%,盐皮质激素受体拮抗剂(MRA)45%,44%,37%,24%;三联疗法(ACEi/ARB/ARNi+β受体阻滞剂+MRA)38%,35%,28%,和15%。CKD患者不太可能开始这些药物治疗,并且不太可能坚持和坚持ACEi/ARB/ARNi,MRA,和三联疗法。在塞子中,CKD患者不太可能重新启动这些药物。多变量校正后的结果与HFmrEF患者的结果一致(n=15114)。
结论:HF和CKD患者不太可能开处方,并为循证治疗开处方。显示出较低的依从性和持久性,即使在eGFR类别中,这些疗法都被推荐,并且在临床试验中显示出疗效。
Half of heart failure (HF) patients have chronic kidney disease (CKD) complicating their pharmacological management. We evaluated physicians\' and patients\' patterns of use of evidence-based medical therapies in HF across CKD stages.
We studied HF patients with reduced (HFrEF) and mildly reduced (HFmrEF) ejection fraction enrolled in the Swedish Heart Failure Registry in 2009-2018. We investigated the likelihood of physicians to prescribe
guideline-recommended therapies to patients with CKD, and of patients to fill the prescriptions within 90 days of incident HF (initiating therapy), to adhere (proportion of days covered ≥80%) and persist (continued use) on these treatments during the first year of therapy. We identified 31 668 patients with HFrEF (median age 74 years, 46% CKD). The proportions receiving a prescription for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors (ACEi/ARB/ARNi) were 96%, 92%, 86%, and 68%, for estimated glomerular filtration rate (eGFR) ≥60, 45-59, 30-44, and <30 ml/min/1.73 m2 , respectively; for beta-blockers 94%, 93%, 92%, and 92%, for mineralocorticoid receptor antagonists (MRAs) 45%, 44%, 37%, 24%; and for triple therapy (combination of ACEi/ARB/ARNi + beta-blockers + MRA) 38%, 35%, 28%, and 15%. Patients with CKD were less likely to initiate these medications, and less likely to adhere to and persist on ACEi/ARB/ARNi, MRA, and triple therapy. Among stoppers, CKD patients were less likely to restart these medications. Results were consistent after multivariable adjustment and in patients with HFmrEF (n = 15 114).
Patients with HF and CKD are less likely to be prescribed and to fill prescriptions for evidence-based therapies, showing lower adherence and persistence, even at eGFR categories where these therapies are recommended and have shown efficacy in clinical trials.