Veterans Affairs Medical Center, Washington, DC; Georgetown University, Washington, DC; MedStar Washington Hospital Center, Washington, DC.
Veterans Affairs Medical Center, Washington, DC; Brigham and Women's Hospital, Boston, Mass.
Am J Med. 2019 Jan;132(1):71-80.e1. doi: 10.1016/j.amjmed.2018.09.011. Epub 2018 Sep 19.
The efficacy of mineralocorticoid receptor antagonists or aldosterone antagonists in heart failure with reduced ejection fraction (HFrEF) is well known. Less is known about their effectiveness in real-world older patients with HFrEF.
Of the 8206 patients with heart failure and ejection fraction ≤35% without prior spironolactone use in the Medicare-linked OPTIMIZE-HF registry, 6986 were eligible for spironolactone therapy based on serum creatinine criteria (men ≤2.5 mg/dL, women ≤2.0 mg/dL) and 865 received a discharge prescription for spironolactone. Using propensity scores for spironolactone use, we assembled a matched cohort of 1724 (862 pairs) patients receiving and not receiving spironolactone, balanced on 58 baseline characteristics (Creatinine Cohort: mean age, 75 years, 42% women, 17% African American). We repeated the above process to assemble a secondary matched cohort of 1638 (819 pairs) patients with estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m (eGFR Cohort: mean age, 75 years, 42% women, 17% African American).
In the matched Creatinine Cohort, spironolactone-associated hazard ratios (95% confidence intervals) for all-cause mortality, heart failure readmission, and combined endpoint of heart failure readmission or all-cause mortality were 0.92 (0.81-1.03), 0.87 (0.77-0.99), and 0.87 (0.79-0.97), respectively. Respective hazard ratios (95% confidence intervals) in the matched eGFR Cohort were 0.87 (0.77-0.98), 0.92 (0.80-1.05), and 0.91 (0.82-1.02).
These findings provide evidence of consistent, albeit modest, clinical effectiveness of spironolactone in older patients with HFrEF regardless of renal eligibility criteria used. Additional strategies are needed to improve the effectiveness of aldosterone antagonists in clinical practice.
醛固酮受体拮抗剂或盐皮质激素受体拮抗剂在射血分数降低的心力衰竭（HFrEF）中的疗效众所周知。然而，关于它们在射血分数降低的真实世界中老年患者中的有效性知之甚少。
在医疗保险相关 OPTIMIZE-HF 注册中心的 8206 例射血分数≤35%且无螺内酯既往使用史的心力衰竭患者中，根据血清肌酐标准（男性≤2.5mg/dL，女性≤2.0mg/dL），有 6986 例患者符合螺内酯治疗条件，865 例患者出院时开具了螺内酯处方。使用螺内酯使用倾向评分，我们为 1724 例（862 对）接受和未接受螺内酯治疗的患者组装了一个匹配队列，在 58 个基线特征上平衡（肌酐队列：平均年龄 75 岁，42%为女性，17%为非裔美国人）。我们重复了上述过程，为估计肾小球滤过率（eGFR）≥30mL/min/1.73m 的 1638 例（819 对）患者组装了一个二级匹配队列（eGFR 队列：平均年龄 75 岁，42%为女性，17%为非裔美国人）。
在匹配的肌酐队列中，螺内酯相关的全因死亡率、心力衰竭再入院和心力衰竭再入院或全因死亡率的复合终点的风险比（95%置信区间）分别为 0.92（0.81-1.03）、0.87（0.77-0.99）和 0.87（0.79-0.97）。在匹配的 eGFR 队列中，相应的风险比（95%置信区间）分别为 0.87（0.77-0.98）、0.92（0.80-1.05）和 0.91（0.82-1.02）。
这些发现提供了证据，证明无论使用何种肾资格标准，螺内酯在射血分数降低的老年心力衰竭患者中均具有一致但适度的临床疗效。需要采取额外的策略来提高醛固酮拮抗剂在临床实践中的有效性。
