Khazanie Prateeti, Liang Li, Curtis Lesley H, Butler Javed, Eapen Zubin J, Heidenreich Paul A, Bhatt Deepak L, Peterson Eric D, Yancy Clyde W, Fonarow Gregg C, Hernandez Adrian F
From the Duke Clinical Research Institute (P.K., L.L., L.H.C., Z.J.E., E.D.P., A.F.H.) and Department of Medicine (P.K., L.H.C., Z.J.E., E.D.P., A.F.H.), Duke University School of Medicine, Durham, NC; Department of Medicine, Emory University, Atlanta, GA (J.B.); VA Palo Alto Healthcare System, CA (P.A.H.); Heart and Vascular Center and Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Department of Medicine, Northwestern University, Chicago, IL (C.W.Y.); and Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles (G.C.F.).
Circ Heart Fail. 2016 Feb;9(2):e002444. doi: 10.1161/CIRCHEARTFAILURE.115.002444.
In clinical trials, hydralazine-isosorbide dinitrate (H-ISDN) for heart failure with reduced ejection fraction reduced morbidity and mortality among black patients and patients with intolerance to angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. The effectiveness of H-ISDN in clinical practice is unknown.
Using data from a clinical registry linked with Medicare claims, we examined the use and outcomes of H-ISDN between 2005 and 2011 among older patients hospitalized with heart failure and reduced ejection fraction. We adjusted for demographic and clinical characteristics using Cox proportional hazards models and inverse probability weighting. Among 4663 eligible patients, 22.7% of black patients and 18.2% of patients not on an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker were newly prescribed H-ISDN therapy at discharge. By 3 years, the cumulative incidence rates of mortality and readmission were similar between treated and untreated patients. After multivariable adjustment, 3-year outcomes remained similar for mortality [black patients: hazard ratio (HR), 0.92; 95% confidence interval (CI), 0.75-1.13; other patients: HR, 0.93; 95% CI, 0.79-1.09], all-cause readmission (black patients: HR, 0.98; 95% CI, 0.84-1.13; other patients: HR, 1.02; 95% CI, 0.90-1.17), and cardiovascular readmission (black patients: HR, 0.99; 95% CI, 0.82-1.19; other patients: HR, 0.94; 95% CI, 0.81-1.09). A post hoc analysis of Medicare Part D data revealed low postdischarge adherence to therapy.
Guideline-recommended initiation of H-ISDN therapy at hospital discharge was uncommon, and adherence was low. For both black patients and patients of other races, there were no differences in outcomes between those treated and untreated at discharge.
在临床试验中，肼屈嗪-硝酸异山梨酯（H-ISDN）用于射血分数降低的心力衰竭患者，可降低黑人患者以及对血管紧张素转换酶抑制剂或血管紧张素II受体阻滞剂不耐受患者的发病率和死亡率。H-ISDN在临床实践中的有效性尚不清楚。
利用与医疗保险理赔相关的临床登记数据，我们研究了2005年至2011年间因射血分数降低的心力衰竭而住院的老年患者中H-ISDN的使用情况和结局。我们使用Cox比例风险模型和逆概率加权法对人口统计学和临床特征进行了调整。在4663例符合条件的患者中，22.7%的黑人患者和18.2%未使用血管紧张素转换酶抑制剂或血管紧张素II受体阻滞剂的患者在出院时新接受了H-ISDN治疗。到3年时，治疗组和未治疗组患者的死亡率和再入院累积发生率相似。多变量调整后，3年结局在死亡率方面仍然相似[黑人患者：风险比（HR），0.92；95%置信区间（CI），0.75-1.13；其他患者：HR，0.93；95%CI，0.79-1.09]，全因再入院（黑人患者：HR，0.98；95%CI，0.84-1.不13；其他患者：HR，1.02；95%CI，0.90-1.17），以及心血管再入院（黑人患者：HR，0.99；95%CI，0.82-1.19；其他患者：HR，0.94；95%CI，0.81-1.09）。对医疗保险D部分数据的事后分析显示出院后治疗依从性较低。
指南推荐的出院时开始使用H-ISDN治疗的情况并不常见，且依从性较低。对于黑人患者和其他种族的患者，出院时接受治疗和未接受治疗的患者在结局方面没有差异。
