Veterans Affairs Medical Center, Washington, DC; Georgetown University, Washington, DC.
Veterans Affairs Medical Center, Providence, Rhode Island; Brown University, Providence, Rhode Island.
J Am Coll Cardiol. 2019 Aug 6;74(5):617-627. doi: 10.1016/j.jacc.2019.05.064.
The deleterious effects of discontinuation of digoxin on outcomes in ambulatory patients with chronic heart failure (HF) with reduced ejection fraction (HFrEF) receiving angiotensin-converting enzyme inhibitors are well-documented.
The authors sought to determine the relationship between digoxin discontinuation and outcomes in hospitalized patients with HFrEF receiving more contemporary guideline-directed medical therapies including beta-blockers and mineralocorticoid receptor antagonists.
Of the 11,900 hospitalized patients with HFrEF (EF ≤45%) in the Medicare-linked OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry, 3,499 received pre-admission digoxin, which was discontinued in 721 patients. Using propensity scores for digoxin discontinuation, estimated for each of the 3,499 patients, a matched cohort of 698 pairs of patients, balanced on 50 baseline characteristics (mean age 76 years; mean EF 28%; 41% women; 13% African American; 65% on beta-blockers) was assembled.
Four-year post-discharge, digoxin discontinuation was associated with significantly higher risks of HF readmission (hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 1.05 to 1.39; p = 0.007), all-cause readmission (HR: 1.16; 95% CI: 1.04 to 1.31; p = 0.010), and the combined endpoint of HF readmission or all-cause mortality (HR: 1.20; 95% CI: 1.07 to 1.34; p = 0.002), but not all-cause mortality (HR: 1.09; 95% CI: 0.97 to 1.24; p = 0.163). Discontinuation of digoxin was associated with a significantly higher risk of all 4 outcomes at 6 months and 1 year post-discharge. At 30 days, digoxin discontinuation was associated with higher risks of all-cause mortality (HR: 1.80; 95% CI: 1.26 to 2.57; p = 0.001) and the combined endpoint (HR: 1.36; 95% CI: 1.09 to 1.71; p = 0.007), but not of HF readmission (HR: 1.19; 95% CI: 0.90 to 1.59; p = 0.226) or all-cause readmission (HR: 1.03; 95% CI: 0.84 to 1.26; p = 0.778).
Among hospitalized older patients with HFrEF on more contemporary guideline-directed medical therapies, discontinuation of pre-admission digoxin therapy was associated with poor outcomes.
已有充分证据表明，在接受血管紧张素转换酶抑制剂（ACEI）治疗的伴有射血分数降低的慢性心力衰竭（HFrEF）的门诊患者中，停用地高辛会对结局产生有害影响。
作者旨在确定在接受更现代的指南指导的药物治疗（包括β受体阻滞剂和盐皮质激素受体拮抗剂）的住院 HFrEF 患者中，停用地高辛与结局之间的关系。
在医疗保险相关的 OPTIMIZE-HF（有组织的启动心力衰竭住院患者救生治疗计划）注册中心的 11900 名 HFrEF（EF≤45%）住院患者中，3499 名患者接受了入院前地高辛治疗，其中 721 名患者停用了地高辛。使用每个 3499 名患者的地高辛停用倾向评分，估计了一个配对的 698 对患者的匹配队列，在 50 个基线特征上平衡（平均年龄 76 岁；平均 EF 28%；41%为女性；13%为非裔美国人；65%接受β受体阻滞剂治疗）。
出院后 4 年，地高辛停药与 HF 再入院（风险比[HR]：1.21；95%置信区间[CI]：1.05 至 1.39；p=0.007）、全因再入院（HR：1.16；95%CI：1.04 至 1.31；p=0.010）和 HF 再入院或全因死亡（HR：1.20；95%CI：1.07 至 1.34；p=0.002）的风险显著增加相关，但与全因死亡率（HR：1.09；95%CI：0.97 至 1.24；p=0.163）无关。地高辛停药与出院后 6 个月和 1 年的所有 4 项结局风险显著增加相关。在 30 天时，地高辛停药与全因死亡率（HR：1.80；95%CI：1.26 至 2.57；p=0.001）和复合终点（HR：1.36；95%CI：1.09 至 1.71；p=0.007）的风险增加相关，但与 HF 再入院（HR：1.19；95%CI：0.90 至 1.59；p=0.226）或全因再入院（HR：1.03；95%CI：0.84 至 1.26；p=0.778）无关。
在接受更现代的指南指导的药物治疗的住院老年 HFrEF 患者中，停用入院前地高辛治疗与不良结局相关。
