Huusko Jenni, Purmonen Timo, Toppila Iiro, Lassenius Mariann, Ukkonen Heikki
Novartis Finland Oy, Espoo, Finland.
Medaffcon Oy, Espoo, Finland.
ESC Heart Fail. 2020 Jun;7(3):1039-1048. doi: 10.1002/ehf2.12665. Epub 2020 Mar 18.
The study aimed at investigating the use of guideline-recommended diagnostic tools and medication in patients with heart failure (HF) in specialty care in Southwest Finland. We also compared the characteristics of the diagnosed and undiagnosed patients as well as laboratory tests, procedures, and treatments in everyday clinical practice.
Patients diagnosed with HF, cardiomyopathy, or hypertension-induced heart disease (n = 20 878, primary cohort) or not diagnosed with HF but having a record of elevated N-terminal pro-brain natriuretic peptide (NT-proBNP) (>125 ng/L, n = 24 321, secondary cohort) were included in the study from the specialty care patient register of the Hospital District of Southwest Finland during the years 2005-2017. Among patients with an International Classification of Diseases, Tenth Revision (ICD-10) code for HF, only 50% had ejection fraction (EF) data to be found by data mining from the electronic health records. Of these patients, 39% (n = 4042) had EF ≤ 40% [HF with reduced EF (HFrEF)] and 61% (n = 6347) had EF > 40%. Elevated NT-proBNP together with EF > 40% narrowed down the number to 4590 patients, a population defined as HF with preserved EF (HFpEF) patients. HFpEF patients were further stratified into HF with mildly reduced EF (HFmrEF; EF 41-50%, n = 1468) and EF > 50% patients (n = 3122) to compare clinical characteristics. NT-proBNP was higher within the HFrEF patients vs. HFpEF {4580 [inter-quartile range (IQR): 2065-9765] vs. 2900 [2065-9765] ng/L, P < 0.001}. Baseline co-morbidities differed between HFpEF and HFrEF groups. Further, HFpEF patients had more procedures and lab tests taken prior to diagnosis than had HFrEF patients. HFmrEF patients were found to resemble more HFrEF than EF > 50% patients. In 70% (n = 17 156) of patients in the secondary cohort, the NT-proBNP concentrations were >300 ng/L, median was 1090 (IQR 551-2558) ng/L and EF 58.4 ± 12.1% (n with EF available = 6845). Reduced EF was present in 6.8% of patients lacking HF diagnosis.
Half of the patients with ICD-10 code for HF did not have EF data available after a visit at specialty care. In particular, the diagnosis of HFpEF seems challenging, reflected as an increase in procedures and laboratory test preceding diagnosis compared with those in HFrEF patients. Also, a large proportion of patients did not have HF diagnosis, yet they presented elevated NT-proBNP concentrations and clinical characteristics resembling those of HFpEF patients.
本研究旨在调查芬兰西南部专科护理中，心力衰竭（HF）患者使用指南推荐的诊断工具和药物的情况。我们还比较了已确诊和未确诊患者的特征，以及日常临床实践中的实验室检查、操作和治疗情况。
从芬兰西南部医院区2005 - 2017年的专科护理患者登记册中纳入了被诊断为HF、心肌病或高血压性心脏病的患者（n = 20878，主要队列），以及未被诊断为HF但有N末端脑钠肽前体（NT-proBNP）升高记录（>125 ng/L，n = 24321，次要队列）。在患有国际疾病分类第十版（ICD - 10）HF编码的患者中，通过从电子健康记录中进行数据挖掘，仅50%的患者有射血分数（EF）数据。在这些患者中，39%（n = 4042）的EF≤40%[射血分数降低的心力衰竭（HFrEF）]，61%（n = 6347）的EF>40%。NT-proBNP升高且EF>40%将患者数量缩小至4590例，这一人群被定义为射血分数保留的心力衰竭（HFpEF）患者。HFpEF患者进一步分层为轻度射血分数降低的心力衰竭（HFmrEF；EF 41 - 50%，n = 1468）和EF>50%的患者（n = 3122）以比较临床特征。HFrEF患者的NT-proBNP高于HFpEF{4580[四分位间距（IQR）：2065 - 9765]与2900[2065 - 9765]ng/L，P<0.001}。HFpEF和HFrEF组之间的基线合并症不同。此外，HFpEF患者在诊断前接受的操作和实验室检查比HFrEF患者更多。发现HFmrEF患者比EF>50%的患者更类似于HFrEF患者。在次要队列中70%（n = 17156）的患者中，NT-proBNP浓度>300 ng/L，中位数为1090（IQR 551 - 2558）ng/L，EF为58.4±12.1%（有EF数据的n = 6845）。在缺乏HF诊断的患者中，6.8%存在射血分数降低。
患有ICD - 10 HF编码的患者中，有一半在专科护理就诊后没有可用的EF数据。特别是，HFpEF的诊断似乎具有挑战性，这表现为与HFrEF患者相比，诊断前的操作和实验室检查增加。此外，很大一部分患者没有HF诊断，但他们的NT-proBNP浓度升高，且临床特征与HFpEF患者相似。
