CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie Clinique, Nancy, France.
Université de Lorraine, APEMAC, Nancy, France.
Pharmacoepidemiol Drug Saf. 2019 Nov;28(11):1489-1500. doi: 10.1002/pds.4868. Epub 2019 Jul 24.
The purpose of the study is to describe the trajectories of oral medication prescriptions in patients with heart failure with reduced ejection fraction (HFrEF) over 3 years after discharge from hospitalization for heart failure. We then evaluated the adherence of these prescriptions to the European Society of Cardiology (ESC) guideline-recommended medications and identified patient characteristics associated with nonadherence.
We used data from the EPICAL2 cohort study. HFrEF patients who had completed prescriptions at discharge and at 6-month follow-up were included and followed for 36 months. The following medication agents were considered adherent to guidelines: renin-angiotensin system (RAS) blockers [angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin-receptor blocker (ARB)] plus a β-blocker (BB) or RAS blocker plus BB plus mineralocorticoid receptor antagonists (MRAs). The evolution of drug prescriptions and the adherence to ESC guidelines were assessed by using sequence analysis and clustering approaches. Patient characteristics associated with nonadherence were identified by logistic regression analyses.
A typology of four therapeutic clusters was obtained, among which two clusters were adherent to recommendations and two were not. The adherent clusters consisted of bitherapy (RAS blockers-BB) and tritherapy (RAS blockers-BB-MRA) for about 64% of patients and remain stable over time. The nonadherent clusters consisted of nonprescription of BB for about 22% of patients or nonprescription of RAS blocker for about 14%. The main reason for nonprescription of BB was a concomitant obstructive airway disease (asthma or COPD) but was a concomitant chronic kidney disease for nonprescription of RAS blocker.
Adherence to guideline-recommended medications while being hospitalized is of great importance because prescriptions are quite stable over time after discharge. HFrEF patients are most often older, with various comorbidities, such as chronic kidney disease or asthma/COPD, which importantly limit physicians' ability to prescribe recommended drugs, leading to suboptimal adherence to guidelines.
本研究旨在描述心力衰竭射血分数降低（HFrEF）患者出院后 3 年内口服药物治疗的轨迹。然后，我们评估了这些处方对欧洲心脏病学会（ESC）指南推荐药物的依从性，并确定了与不依从相关的患者特征。
我们使用了 EPICAL2 队列研究的数据。纳入了出院时和 6 个月随访时完成处方的 HFrEF 患者，并随访 36 个月。以下药物被认为符合指南：肾素-血管紧张素系统（RAS）阻滞剂[血管紧张素转换酶抑制剂（ACEI）或血管紧张素受体阻滞剂（ARB）]加β受体阻滞剂（BB）或 RAS 阻滞剂加 BB 加盐皮质激素受体拮抗剂（MRAs）。通过序列分析和聚类方法评估药物处方的演变和对 ESC 指南的依从性。使用逻辑回归分析确定与不依从相关的患者特征。
得到了四种治疗聚类的类型，其中两种聚类符合建议，两种聚类不符合。依从性聚类包括 RAS 阻滞剂-BB 双药治疗和 RAS 阻滞剂-BB-MRA 三药治疗，约占 64%的患者，且随时间保持稳定。不依从聚类包括约 22%的患者未开 BB 或约 14%的患者未开 RAS 阻滞剂。未开 BB 的主要原因是伴有阻塞性气道疾病（哮喘或 COPD），而未开 RAS 阻滞剂的主要原因是伴有慢性肾脏病。
住院期间遵循指南推荐的药物治疗非常重要，因为出院后处方随时间相当稳定。HFrEF 患者通常年龄较大，伴有各种合并症，如慢性肾脏病或哮喘/COPD，这重要限制了医生开具推荐药物的能力，导致对指南的依从性不佳。
