泰国急性冠状动脉综合征患者出院时最佳药物治疗趋势及临床结局。
Trends in optimal medical therapy at discharge and clinical outcomes in patients with acute coronary syndrome in Thailand.
机构信息
School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand; Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand; Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao 56000, Thailand; Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.
Department of Pharmacy, Buddhachinaraj Regional Hospital, Phitsanulok, Thailand.
出版信息
J Cardiol. 2021 Jun;77(6):669-676. doi: 10.1016/j.jjcc.2020.12.015. Epub 2021 Jan 15.
BACKGROUND
Optimal medical therapy (OMT) is recommended for patients with acute coronary syndrome (ACS) at discharge. This study aimed to assess temporal trends of OMT prescription as a five-drug regimen at discharge and its association with clinical outcomes in patients with ACS in Thailand.
METHODS
A retrospective cohort study was conducted in a tertiary-care medical center in Thailand. Data were collected from an electronic medical database. Patients were categorized into OMT or non-OMT groups based on their discharge medications. OMT was defined as a combination of aspirin and P2Y12 inhibitors, statins, beta-blockers, and angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers. The primary outcome was 1-year all-cause mortality. The secondary outcome was major adverse cardiac events (MACE) which was defined as a composite of non-fatal myocardial infarction, non-fatal stroke, and all-cause mortality. The prescription trends were also estimated. A multivariate Cox's proportional hazard model was used to assess the association of OMT prescriptions at discharge with all-cause mortality and MACE.
RESULTS
A total of 3531 patients discharged with ACS [mean age, 69.5 (SD 12.4) years; 58.3% male] were identified. Only 42.6% were discharged with OMT. The rates of OMT prescriptions did not change over time. However, the prescription of OMT with high-intensity statin was significantly increased from 5.0% in 2013 to 38.3% in 2018 (p for trend <0.001). Multivariable analyses indicated that OMT significantly reduced all-cause mortality (adjusted HR: 0.77; 95%CI: 0.63-0.95; p=0.012) and MACE (adjusted HR 0.84; 95%CI: 0.71-0.99; p = 0.044). Subgroup analysis indicated that patients receiving OMT with high-intensity statins exhibited survival benefits (adjusted HR: 0.72; 95%CI: 0.56-0.92; p=0.008).
CONCLUSIONS
The five-drugs comprising OMT were associated with a reduction in all-cause mortality and MACE in patients with ACS. Nevertheless, OMT prescribing remains underused and could be enhanced in the real-world setting.
背景
对于急性冠状动脉综合征（ACS）患者，建议在出院时采用最佳药物治疗（OMT）。本研究旨在评估泰国 ACS 患者出院时采用五种药物治疗方案的 OMT 处方趋势及其与临床结局的关系。
方法
本研究为泰国一家三级保健医疗中心的回顾性队列研究。数据来自电子病历数据库。根据出院时的药物治疗情况，将患者分为 OMT 组或非 OMT 组。OMT 定义为阿司匹林和 P2Y12 抑制剂、他汀类药物、β受体阻滞剂和血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂的联合治疗。主要结局为 1 年全因死亡率。次要结局为主要不良心脏事件（MACE），定义为非致死性心肌梗死、非致死性卒中和全因死亡率的复合结局。还估计了处方趋势。采用多变量 Cox 比例风险模型评估出院时 OMT 处方与全因死亡率和 MACE 的相关性。
结果
共纳入 3531 例 ACS 出院患者[平均年龄 69.5（12.4）岁；58.3%为男性]。仅有 42.6%的患者出院时接受了 OMT。OMT 处方率并未随时间而变化。然而，高强度他汀类药物 OMT 的处方率显著增加，从 2013 年的 5.0%增加到 2018 年的 38.3%（趋势检验 p<0.001）。多变量分析表明，OMT 显著降低了全因死亡率（调整后的 HR：0.77；95%CI：0.63-0.95；p=0.012）和 MACE（调整后的 HR 0.84；95%CI：0.71-0.99；p=0.044）。亚组分析表明，接受高强度他汀类药物 OMT 的患者生存获益（调整后的 HR：0.72；95%CI：0.56-0.92；p=0.008）。
结论
包含 OMT 的五种药物与 ACS 患者的全因死亡率和 MACE 降低相关。然而，OMT 的处方仍未得到充分应用，在真实世界环境中可以进一步加强。
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