Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.
Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
JACC Heart Fail. 2020 Nov;8(11):943-953. doi: 10.1016/j.jchf.2020.05.013. Epub 2020 Aug 12.
This study sought to characterize in-hospital treatment patterns and associated patient outcomes among patients hospitalized for heart failure (HF) in U.S. clinical practice.
Hospitalizations for HF are common and associated with poor patient outcomes. Real-world patterns of in-hospital treatment, including diuretic therapy, in contemporary U.S. practice are unknown.
Using Optum de-identified Electronic Health Record data from 2007 through 2018, patients hospitalized for a primary diagnosis of HF (ejection fraction ≤40%) and who were hemodynamically stable at admission, without concurrent acute coronary syndrome or end-stage renal disease, and treated with intravenous (IV) diuretic agents within 48 h of admission were identified. Patients were categorized into 1 of 4 mutually exclusive hierarchical treatment groups defined by complexity of treatment during hospitalization (intensified treatment with mechanical support or IV vasoactive therapy, IV diuretic therapy reinitiated after discontinuation for ≥1 day without intensified treatment, IV diuretic dose increase/combination diuretic treatment without intensified treatment or IV diuretic reinitiation, or uncomplicated).
Of 22,677 patients hospitalized for HF with reduced ejection fraction (HFrEF), 66% had uncomplicated hospitalizations without escalation of treatment beyond initial IV diuretic therapy. Among 7,809 remaining patients, the highest level of therapy received was IV diuretic dose increase/combination diuretic treatment in 25%, IV diuretic reinitiation in 36%, and intensified therapy in 39%. Overall, 19% of all patients had reinitiation of IV diuretic agents (26% of such patients had multiple instances), 12% were simultaneously treated with multiple diuretics, and 61% were transitioned to oral diuretic agents before discharge. Compared with uncomplicated treatment, IV diuretic reinitiation and intensified treatment were associated with significantly longer median length of stay (uncomplicated: 4 days; IV diuretic reinitiation: 8 days; intensified: 10 days) and higher rates of in-hospital (uncomplicated: 1.6%; IV diuretic reinitiation: 4.2%; intensified: 13.2%) and 30-day post-discharge mortality (uncomplicated: 5.2%; IV diuretic reinitiation: 9.7%; intensified: 12.7%).
In this contemporary real-world population of U.S. patients hospitalized for HFrEF, one-third of patients had in-hospital treatment escalated beyond initial IV diuretic therapy. These more complex treatment patterns were associated with highly variable patterns of diuretic use, longer hospital lengths of stay, and higher mortality. Standardized and evidence-based approaches are needed to improve the efficiency and effectiveness of in-hospital HFrEF care.
本研究旨在描述美国临床实践中因心力衰竭（HF）住院患者的院内治疗模式及相关患者结局。
HF 住院治疗较为常见，且与患者预后不良相关。目前尚不清楚当代美国实际的院内治疗模式，包括利尿剂治疗。
利用 2007 年至 2018 年 Optum 去识别电子健康记录数据，入选因主要诊断为 HF（射血分数≤40%）且入院时血流动力学稳定、无急性冠状动脉综合征或终末期肾病、且入院 48 h 内接受静脉（IV）利尿剂治疗的患者。根据住院期间治疗的复杂程度，将患者分为 4 个互斥的分层治疗组之一：强化治疗（机械支持或 IV 血管活性治疗）、IV 利尿剂治疗停药≥1 天而无强化治疗、IV 利尿剂剂量增加/联合利尿剂治疗而无强化治疗或 IV 利尿剂再开始、或无并发症。
在 22677 例射血分数降低的心力衰竭（HFrEF）患者中，66%的患者住院治疗无并发症，无需进一步升级治疗，仅接受初始 IV 利尿剂治疗。在其余 7809 例患者中，接受的最高级别治疗为 IV 利尿剂剂量增加/联合利尿剂治疗（25%）、IV 利尿剂再开始（36%）和强化治疗（39%）。总体而言，19%的患者重新开始 IV 利尿剂治疗（26%的患者多次重新开始），12%的患者同时使用多种利尿剂，61%的患者在出院前转为口服利尿剂。与无并发症治疗相比，IV 利尿剂再开始和强化治疗的中位住院时间明显延长（无并发症：4 天；IV 利尿剂再开始：8 天；强化治疗：10 天），且院内（无并发症：1.6%；IV 利尿剂再开始：4.2%；强化治疗：13.2%）和 30 天出院后死亡率更高（无并发症：5.2%；IV 利尿剂再开始：9.7%；强化治疗：12.7%）。
在这项美国当代真实世界的 HFrEF 住院患者人群中，有三分之一的患者院内治疗升级，超出初始 IV 利尿剂治疗。这些更复杂的治疗模式与利尿剂使用的高度可变模式、更长的住院时间和更高的死亡率相关。需要采用标准化和基于证据的方法来改善心力衰竭住院治疗的效率和效果。
