多种心血管药物治疗对缺血性卒中和短暂性脑缺血发作后死亡率的影响。
Impact of multiple cardiovascular medications on mortality after an incidence of ischemic stroke or transient ischemic attack.
机构信息
Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK.
Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong.
出版信息
BMC Med. 2021 Feb 3;19(1):24. doi: 10.1186/s12916-021-01900-1.
BACKGROUND
To manage the risk factors and to improve clinical outcomes, patients with stroke commonly receive multiple cardiovascular medications. However, there is a lack of evidence on the optimum combination of medication therapy in the primary care setting after ischemic stroke. Therefore, this study aimed to investigate the effect of multiple cardiovascular medications on long-term survival after an incident stroke event (ischemic stroke or transient ischemic attack (TIA)).
METHODS
This study consisted of 52,619 patients aged 45 and above with an incident stroke event between 2007 and 2016 in The Health Improvement Network database. We estimated the risk of all-cause mortality in patients with multiple cardiovascular medications versus monotherapy using a marginal structural model.
RESULTS
During an average follow-up of 3.6 years, there were 9230 deaths (7635 in multiple cardiovascular medication groups and 1595 in the monotherapy group). Compared with patients prescribed monotherapy only, the HRs of mortality were 0.82 (95% CI 0.75-0.89) for two medications, 0.65 (0.59-0.70) for three medications, 0.61 (0.56-0.67) for four medications, 0.60 (0.54-0.66) for five medications and 0.66 (0.59-0.74) for ≥ six medications. Patients with any four classes of antiplatelet agents (APAs), lipid-regulating medications (LRMs), angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), beta-blockers, diuretics and calcium channel blockers (CCBs) had the lowest risk of mortality (HR 0.51, 95% CI 0.46-0.57) versus any one class. The combination containing APAs, LRMs, ACEIs/ARBs and CCBs was associated with a 61% (95% CI 53-68%) lower risk of mortality compared with APAs alone.
CONCLUSION
Our results suggested that combination therapy of four or five cardiovascular medications may be optimal to improve long-term survival after incident ischemic stroke or TIA. APAs, LRMs, ACEIs/ARBs and CCBs were the optimal constituents of combination therapy in the present study.
背景
为了管理风险因素并改善临床结局，中风患者通常会接受多种心血管药物治疗。然而，在缺血性中风后，初级保健环境中药物治疗的最佳组合缺乏证据。因此，本研究旨在调查多种心血管药物对事件性中风（缺血性中风或短暂性脑缺血发作（TIA））后长期生存的影响。
方法
本研究纳入了 2007 年至 2016 年间在健康改善网络数据库中发生中风事件（缺血性中风或 TIA）的 52619 名 45 岁及以上的患者。我们使用边缘结构模型估计了多种心血管药物治疗与单药治疗的全因死亡率风险。
结果
在平均 3.6 年的随访期间，有 9230 例死亡（多药治疗组 7635 例，单药治疗组 1595 例）。与仅接受单药治疗的患者相比，使用两种药物的死亡率 HR 为 0.82（95%CI 0.75-0.89），使用三种药物的 HR 为 0.65（0.59-0.70），使用四种药物的 HR 为 0.61（0.56-0.67），使用五种药物的 HR 为 0.60（0.54-0.66），使用≥六种药物的 HR 为 0.66（0.59-0.74）。使用所有四类抗血小板药物（APAs）、调脂药物（LRMs）、血管紧张素转换酶抑制剂（ACEIs）/血管紧张素受体阻滞剂（ARBs）、β受体阻滞剂、利尿剂和钙通道阻滞剂（CCBs）的患者死亡风险最低（HR 0.51，95%CI 0.46-0.57），与仅使用一种类别相比。与单独使用 APAs 相比，包含 APAs、LRMs、ACEIs/ARBs 和 CCBs 的联合治疗可降低 61%（95%CI 53-68%）的死亡风险。
结论
我们的结果表明，联合使用四种或五种心血管药物治疗可能是改善缺血性中风或 TIA 后长期生存的最佳方法。在本研究中，APAs、LRMs、ACEIs/ARBs 和 CCBs 是联合治疗的最佳成分。
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