Department of Medicine, University of Toronto, Toronto, Ontario.
ICES, Toronto, Ontario; Institute for Health Policy, Management and Evaluation Toronto, Ontario.
Am J Med. 2021 May;134(5):672-681.e4. doi: 10.1016/j.amjmed.2020.10.017. Epub 2020 Nov 9.
The impact of guideline-directed medical therapy for coronary heart disease in those hospitalized with acute heart failure is unknown.
We studied guideline-directed medical therapies for coronary disease: angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), beta-adrenoreceptor antagonists, antiplatelet agents or anticoagulants, and statins. Using inverse probability of treatment weighting the propensity score, we examined associations of guideline-directed medical therapy intensity (categorized as low [0-1], high [2-3], or very high [4] number of drugs) with mortality in 1873 patients with angina, troponin elevation, or prior myocardial infarction.
At discharge, 0-1, 2-3, and 4 medications were prescribed in 467 (25%), 705 (38%), and 701 (37%) patients, respectively. Relative to those prescribed 0-1 drugs (reference), all-cause mortality was lower with 2-3 (hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.28-0.84, P = 0.009) or all 4 drug classes (HR 0.56, 95% CI 0.33-0.96, P = 0.034) over 181-365 days, with similar reductions present from 0-180 days. In those with heart failure with preserved ejection fraction, mortality trended lower with 2-3 drug classes (HR 0.43, 95% CI 0.18-1.02, P = 0.054) and was significantly reduced with 4 drugs (HR 0.32, 95%CI 0.12-0.84, P = 0.021) during 0-180 day follow-up. In heart failure with reduced ejection fraction, all-cause mortality was reduced during both 0-180 and 181-365 days when discharged on 2-3 (HR 0.30 for 181-365 days, 95%CI 0.14-0.64, P = 0.002) or all 4 drug classes (HR 0.43, 95%CI 0.19-0.95, P = 0.038).
Increasing guideline-directed medical therapy intensity for coronary heart disease resulted in lower mortality in patients with acute ischemic heart failure with both preserved and reduced ejection fractions.
尚不清楚指导医学治疗对急性心力衰竭住院患者冠心病的影响。
我们研究了冠心病的指导医学治疗：血管紧张素转换酶（ACE）抑制剂或血管紧张素 II 受体阻滞剂（ARB）、β-肾上腺素能受体拮抗剂、抗血小板药物或抗凝剂以及他汀类药物。我们使用逆概率治疗加权倾向评分，检查了 1873 例心绞痛、肌钙蛋白升高或既往心肌梗死患者的指南指导的药物治疗强度（分为低[0-1]、高[2-3]或非常高[4]个药物）与死亡率之间的关系。
出院时，467 例（25%）、705 例（38%）和 701 例（37%）患者分别开具了 0-1、2-3 和 4 种药物。与服用 0-1 种药物的患者（参考）相比，在 181-365 天内，服用 2-3 种（风险比[HR]0.48，95%置信区间[CI]0.28-0.84，P=0.009）或所有 4 种药物类别（HR 0.56，95%CI 0.33-0.96，P=0.034）的患者全因死亡率均较低，在 0-180 天内也有类似的降低。在射血分数保留的心力衰竭患者中，服用 2-3 种药物类别（HR 0.43，95%CI 0.18-1.02，P=0.054）和服用 4 种药物（HR 0.32，95%CI 0.12-0.84，P=0.021）时，180 天内死亡率呈下降趋势。在射血分数降低的心力衰竭患者中，在 0-180 天和 181-365 天期间，当服用 2-3 种（181-365 天 HR0.30，95%CI0.14-0.64，P=0.002）或所有 4 种药物类别（HR0.43，95%CI0.19-0.95，P=0.038）时，全因死亡率均降低。
对于急性缺血性心力衰竭伴射血分数保留和降低的患者，增加冠心病的指导医学治疗强度可降低死亡率。
