Lee Douglas S, Tu Jack V, Juurlink David N, Alter David A, Ko Dennis T, Austin Peter C, Chong Alice, Stukel Therese A, Levy Daniel, Laupacis Andreas
Institute for Clinical Evaluative Sciences, Department of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
JAMA. 2005 Sep 14;294(10):1240-7. doi: 10.1001/jama.294.10.1240.
Patients with heart failure have a wide spectrum of mortality risks. To maximize the benefit of available pharmacotherapies, patients with high mortality risk should receive high rates of drug therapy.
To examine patterns of drug therapy and underlying mortality risk in patients with heart failure.
DESIGN, SETTING, AND PATIENTS: In the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) population-based cohort (1999-2001) of 9942 patients with heart failure hospitalized in Ontario, Canada, we evaluated 1418 patients with documented left ventricular ejection fraction of 40% or less and aged 79 years or younger with low-, average-, and high-predicted risk of death within 1 year; all patients survived to hospital discharge. Administration of angiotensin-converting enzyme (ACE) inhibitors, ACE inhibitors or angiotensin II receptor blockers (ARBs), and beta-adrenoreceptor antagonists was evaluated according to predicted risk of death.
Heart failure drug administration rates at time of discharge and 90 days after hospital discharge.
At hospital discharge, prescription rates for patients in the low-, average-, and high-risk groups were 81%, 73%, 60%, respectively, for ACE inhibitors; 86%, 80%, 65%, respectively, for ACE inhibitors or ARBs; and 40%, 33%, 24%, respectively, for beta-adrenoreceptor antagonists (all P<.001 for trend). Within 90 days following hospital discharge, the rates were 83%, 76%, and 61% for ACE inhibitors; 89%, 83%, and 67% for ACE inhibitors or ARBs; and 43%, 36%, and 28% for beta-adrenoreceptor antagonists for the 3 risk groups, respectively (all P<.001 for trend). The pattern of lower rates of drug administration in those patients at increasing risk was maintained up to 1 year postdischarge (P<.001). After accounting for varying survival time and potential contraindications to therapy, low-risk patients were more likely to receive ACE inhibitors or ARBs (adjusted hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.49-1.74) and beta-adrenoreceptor antagonists (HR, 1.80; 95% CI, 1.60-2.01) compared with high-risk patients (both P<.001).
Patients with heart failure at greatest risk of death are least likely to receive ACE inhibitors, ACE inhibitors or ARBs, and beta-adrenoreceptor antagonists. Understanding the reasons underlying this mismatch may facilitate improvements in care and outcomes for patients with heart failure.
心力衰竭患者的死亡风险范围广泛。为了使现有药物治疗的益处最大化，高死亡风险的患者应接受高比例的药物治疗。
研究心力衰竭患者的药物治疗模式及潜在死亡风险。
设计、地点和患者：在加拿大安大略省基于人群的增强心脏有效治疗反馈（EFFECT）队列研究（1999 - 2001年）中，纳入9942例因心力衰竭住院的患者，我们评估了1418例左心室射血分数记录为40%或更低、年龄在79岁及以下且1年内死亡预测风险低、中、高的患者；所有患者均存活至出院。根据预测的死亡风险评估血管紧张素转换酶（ACE）抑制剂、ACE抑制剂或血管紧张素II受体阻滞剂（ARB）以及β-肾上腺素能受体拮抗剂的使用情况。
出院时及出院后90天的心力衰竭药物给药率。
出院时，低、中、高风险组患者ACE抑制剂的处方率分别为81%、73%、60%；ACE抑制剂或ARB的处方率分别为86%、80%、65%；β-肾上腺素能受体拮抗剂的处方率分别为40%、33%、24%（所有趋势P<0.001）。出院后90天内，3个风险组患者ACE抑制剂的使用率分别为83%、76%、61%；ACE抑制剂或ARB的使用率分别为89%、83%、67%；β-肾上腺素能受体拮抗剂的使用率分别为43%、36%、28%（所有趋势P<0.001）。出院后长达1年，死亡风险增加的患者药物给药率较低的模式仍持续存在（P<0.001）。在考虑了不同的生存时间和潜在治疗禁忌后，与高风险患者相比，低风险患者更有可能接受ACE抑制剂或ARB（调整后风险比[HR]，1.61；95%置信区间[CI]，1.49 - 1.74）以及β-肾上腺素能受体拮抗剂（HR，1.80；95%CI，1.60 - 2.01）（两者P<0.001）。
死亡风险最高的心力衰竭患者接受ACE抑制剂、ACE抑制剂或ARB以及β-肾上腺素能受体拮抗剂的可能性最小。了解这种不匹配背后的原因可能有助于改善心力衰竭患者的护理和预后。
