O'Brien Emily C, Wu Jingjing, Schulte Phillip J, Christian Alexander, Laskey Warren, Bhatt Deepak L, Peterson Eric D, Hernandez Adrian F, Fonarow Gregg C
Duke Clinical Research Institute, Durham, NC.
Duke Clinical Research Institute, Durham, NC.
Am Heart J. 2016 Mar;173:27-34. doi: 10.1016/j.ahj.2015.11.014. Epub 2015 Dec 17.
Clinical trial evidence suggests that statin therapy reduces adverse clinical events and provides even greater benefit at high-intensity doses in coronary artery disease (CAD) patients, yet few studies have examined this in clinical practice.
We linked detailed in-hospital data (2005-2009) on 15,729 Get With The Guidelines-CAD patients ≥65 years prescribed statins to Centers for Medicare and Medicaid Services claims. High-intensity statin therapy was defined as discharge prescription of atorvastatin ≥40 mg, rosuvastatin ≥20 mg, or simvastatin 80 mg. We used Kaplan-Meier curves to calculate all-cause mortality, major adverse cardiovascular events (MACEs), and all-cause readmission at 3 years postdischarge; log-rank tests to compare survival via overall statin use and intensity; and Cox proportional hazards regression with inverse propensity weighting to evaluate adjusted rates of adverse events over 3 years postdischarge.
Of 35,903 patients meeting inclusion criteria, 24,367 (67.9%) were discharged on statin. Of 15,729 patients with statin intensity information, 4488 (28.5%) received high-intensity therapy; these recipients were more often younger, male, and had acute myocardial infarction. After inverse propensity weighting adjustment, statin use was associated with significantly lower hazards of mortality (hazard ratio 0.89, 95% CI 0.84-0.93) and MACE (0.92, 0.88-0.96), but not readmission (1.01, 0.97-1.04). High-intensity (vs low/moderate) use was not associated with lower risk of all-cause mortality (1.07, 1.00-1.14), MACE (1.05, 0.99-1.11), or readmission (1.05, 1.00-1.10). Clinically relevant subgroups had similar results.
In older hospitalized CAD patients, use of statin therapy at discharge was associated with improved long-term outcomes. Consistent with current American College of Cardiology/American Heart Association cholesterol guideline recommendations supporting moderate- rather than high-intensity statin therapy in CAD patients >75 years, high-intensity statin therapy was not associated with incremental benefit in this older population.
临床试验证据表明，他汀类药物治疗可减少不良临床事件，并且在冠状动脉疾病（CAD）患者中，高强度剂量能带来更大益处，但很少有研究在临床实践中对此进行检验。
我们将15729例年龄≥65岁且开具了他汀类药物处方的“遵循指南-冠心病”（Get With The Guidelines-CAD）患者2005 - 2009年详细的住院数据与医疗保险和医疗补助服务中心的索赔数据相链接。高强度他汀类药物治疗定义为出院时开具阿托伐他汀≥40毫克、瑞舒伐他汀≥20毫克或辛伐他汀80毫克的处方。我们使用Kaplan-Meier曲线计算出院后3年的全因死亡率、主要不良心血管事件（MACE）和全因再入院率；使用对数秩检验通过总体他汀类药物使用情况和强度来比较生存率；并使用具有逆倾向加权的Cox比例风险回归来评估出院后3年不良事件的调整发生率。
在35903例符合纳入标准的患者中，24367例（67.9%）出院时使用了他汀类药物。在15729例有他汀类药物强度信息的患者中，4488例（28.5%）接受了高强度治疗；这些接受者更常为年轻男性，且患有急性心肌梗死。经过逆倾向加权调整后，使用他汀类药物与死亡率（风险比0.89，95%可信区间0.84 - 0.93）和MACE（0.92，0.88 - 0.96）的风险显著降低相关，但与再入院率（1.01，0.97 - 1.04）无关。高强度（与低/中度相比）使用与全因死亡率（1.07，1.00 - 1.14）、MACE（1.05，0.99 - 1.11）或再入院率（1.05，1.00 - 1.10）的较低风险无关。临床相关亚组有相似结果。
在老年住院CAD患者中，出院时使用他汀类药物治疗与改善长期预后相关。与美国心脏病学会/美国心脏协会当前支持对>75岁CAD患者进行中等强度而非高强度他汀类药物治疗的胆固醇指南建议一致，高强度他汀类药物治疗在该老年人群中未显示出额外益处。
