Carroll Robert, Mudge Alison, Suna Jessica, Denaro Charles, Atherton John
Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Butterfield St., Herston, Qld 4006, Australia; University of Queensland School of Medicine, 288 Herston Road, Qld 4006, Australia.
Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Butterfield St., Herston, Qld 4006, Australia; University of Queensland School of Medicine, 288 Herston Road, Qld 4006, Australia.
Int J Cardiol. 2016 Aug 1;216:121-7. doi: 10.1016/j.ijcard.2016.04.084. Epub 2016 Apr 16.
Heart failure (HF) medications improve clinical outcomes, with optimal doses defined in clinical trials. Patient, provider and system barriers may limit achievement of optimal doses in real life settings, although disease management programs (HF-DMPs) can facilitate up-titration.
Secondary analysis of a prospective cohort of 216 participants recently hospitalized with systolic HF, attending 5 HF-DMPs in Queensland, Australia. Medication history at baseline (6weeks after discharge) and 6months provided data to describe prescription rates, dosage and optimal titration of HF medications, and associations with patient and system factors were explored. At baseline, 94% were on an angiotensin converting enzyme inhibitor/angiotensin II receptor blocker (ACEI/ARB), 94% on a beta-blocker (BB) and 42% on a mineralocorticoid receptor antagonist (MRA). The proportion of participants on optimal doses of ACEI/ARB increased from 38% (baseline) to 52% (6months, p=0.001) and on optimal BB dose from 23% to 49% (p<0.001). Significant barriers to ACEI/ARB up-titration were body mass index (BMI)<25, female gender, polypharmacy, previously diagnosed HF, and tertiary hospital. Significant barriers for BB up-titration were BMI<25, previously diagnosed HF and non-cardiologist care.
Effective up-titration in HF DMPs is influenced by patient, disease and service factors. Better understanding of barriers to effective up-titration in women, normal weight, and established HF patients may help provide targeted strategies for improving outcomes in these groups.
心力衰竭（HF）药物可改善临床结局，临床试验中已确定了最佳剂量。尽管疾病管理项目（HF-DMPs）有助于剂量滴定，但患者、医护人员和系统方面的障碍可能会限制在现实生活中达到最佳剂量。
对澳大利亚昆士兰州参加5个HF-DMPs的216名近期因收缩性HF住院的参与者的前瞻性队列进行二次分析。基线（出院后6周）和6个月时的用药史提供了数据，以描述HF药物的处方率、剂量和最佳滴定情况，并探讨与患者和系统因素的关联。基线时，94%的患者使用血管紧张素转换酶抑制剂/血管紧张素II受体阻滞剂（ACEI/ARB），94%使用β受体阻滞剂（BB），42%使用盐皮质激素受体拮抗剂（MRA）。使用最佳剂量ACEI/ARB的参与者比例从38%（基线）增至52%（6个月，p = 0.001），使用最佳BB剂量的比例从23%增至49%（p < 0.001）。ACEI/ARB滴定的显著障碍包括体重指数（BMI）<25、女性、多种药物联用、既往诊断为HF以及三级医院。BB滴定的显著障碍包括BMI<25、既往诊断为HF以及非心脏病专家护理。
HF-DMPs中的有效滴定受患者、疾病和服务因素影响。更好地了解女性、体重正常以及已确诊HF患者有效滴定的障碍，可能有助于提供针对性策略以改善这些人群的结局。
