Roth Gregory A, Poole Jeanne E, Zaha Rebecca, Zhou Weiping, Skinner Jonathan, Morden Nancy E
Division of Cardiology and Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington.
Division of Cardiology, University of Washington, Seattle, Washington.
J Am Coll Cardiol. 2016 Mar 8;67(9):1062-1069. doi: 10.1016/j.jacc.2015.12.046.
Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) is recommended before primary prevention implantable cardioverter-defibrillator (ICD) placement. Adherence to this recommendation and associated outcomes are unknown.
This study examined the use of GDMT (≥1 prescription filled for both a renin-angiotensin inhibitor [RAI] and a heart failure-approved beta-blocker [HFBB]) within 90 days before primary prevention ICD placement in patients with HFrEF.
Data from the National Cardiovascular Data Registry ICD Registry were merged with a 40% random sample of Medicare administrative data. Prescription fills for recipients of primary prevention ICD between 2007 and 2011 were examined, analyzing GDMT overall and for each U.S. hospital referral region. We identified characteristics associated with GDMT and the association with 1-year mortality.
Among 19,733 patients with HFrEF and primary prevention ICD, 61.1% filled any GDMT before implantation. Across hospital referral regions, GDMT was applied in 51% to 71%. The strongest predictors of any GDMT included absence of chronic renal disease or nonsustained ventricular tachycardia, low-income prescription benefits subsidy, and less recent left ventricular ejection fraction evaluation. Patients receiving GDMT versus those without had a lower 1-year mortality rate after ICD implantation (11.1% vs. 16.2%), even after adjustment for comorbidities, left ventricular ejection fraction, and functional heart failure class.
Rates of GDMT for HFrEF before primary prevention ICD implantation were low, and failure to achieve GDMT was associated with significantly decreased 1-year survival.
对于射血分数降低的心力衰竭（HFrEF）患者，在植入一级预防植入式心脏复律除颤器（ICD）之前，建议进行指南指导的药物治疗（GDMT）。对这一建议的依从性及相关结果尚不清楚。
本研究调查了HFrEF患者在一级预防ICD植入前90天内使用GDMT（肾素 - 血管紧张素抑制剂[RAI]和心力衰竭批准的β受体阻滞剂[HFBB]均至少有1次处方配药）的情况。
将来自国家心血管数据注册中心ICD注册的数据与40%的医疗保险管理数据随机样本合并。对2007年至2011年期间一级预防ICD接受者的处方配药情况进行检查，分析总体GDMT情况以及美国每个医院转诊区域的情况。我们确定了与GDMT相关的特征以及与1年死亡率的关联。
在19733例HFrEF且接受一级预防ICD的患者中，61.1%在植入前使用了任何GDMT。在各个医院转诊区域，GDMT的应用率为51%至71%。任何GDMT的最强预测因素包括无慢性肾病或非持续性室性心动过速、低收入处方福利补贴以及近期左心室射血分数评估较少。植入ICD后，接受GDMT的患者与未接受GDMT的患者相比，1年死亡率较低（11.1%对16.2%），即使在调整合并症、左心室射血分数和心力衰竭功能分级后也是如此。
一级预防ICD植入前HFrEF患者的GDMT使用率较低，未实现GDMT与1年生存率显著降低相关。
