Imperial College Healthcare NHS Trust, London, UK.
Imperial College London, London, UK.
ESC Heart Fail. 2021 Jun;8(3):2334-2337. doi: 10.1002/ehf2.13284. Epub 2021 Mar 11.
Despite medical therapy for heart failure (HF) having proven benefits of improving quality of life and survival, many patients remain under-treated. This may be due to a combination of under-prescription by medical professionals and poor adherence from patients. In HF, as with many other chronic diseases, adherence to medication can deteriorate over time particularly when symptoms are well controlled. Therefore, detecting and addressing non-adherence has a crucial role in the management of HF. Significant flaws and inaccuracies exist in the methods currently used to assess adherence such as patient reporting, pill counts, and pharmacy fill records. We aim to use high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS) to detect metabolites of HF medications in the urine samples of chronic HF patients.
Urine samples were collected from 35 patients in a specialist HF clinic. Patients were included if they had an ejection fraction <45% and were taking at least two disease-modifying HF medications. They were excluded if they had been admitted to hospital for HF in the 3 months preceding clinic attendance. These samples were sent for HPLC-MS and tested for all HF medications prescribed for that patient. A high rate of complete adherence of 89% was detected in these patients, with 94% being partially adherent (at least one HF medication detected) to therapy (at least one HF medication detected). This analysis also highlighted that mineralocorticoid antagonists represent both the most under-prescribed (67%) and poorly adhered (75%) medication class.
This analysis revealed a surprisingly high level of adherence to disease-modifying therapy in chronic HF patients and highlights that most of our 'total' under-treatment is likely to be from a failure to prescribe rather than a failure to adhere. Testing for metabolites of disease-modifying HF drugs in urine using HPLC-MS is feasible and is a useful adjunct to a specialist HF service. At present, the distinction between treatment failure and failure to take treatment is not always clear, which is important because the investigation and potential solutions are different. The former needs initiation of additional therapies and consideration of additional diagnoses, whereas the latter requires strategies to understand reasons underlying poor adherence and collaborative working to improve this: the wrong strategy will be ineffective.
尽管心力衰竭（HF）的医学治疗已被证明可改善生活质量和生存率，但仍有许多患者治疗不足。这可能是由于医疗专业人员处方不足和患者依从性差的综合原因。在 HF 中，与许多其他慢性疾病一样，随着时间的推移，当症状得到很好的控制时，药物的依从性可能会恶化。因此，在 HF 的管理中，检测和解决不依从性具有至关重要的作用。目前用于评估依从性的方法存在重大缺陷和不准确之处，例如患者报告、药丸计数和药房配药记录。我们旨在使用高效液相色谱-串联质谱法（HPLC-MS）检测慢性 HF 患者尿液样本中 HF 药物的代谢物。
从专科 HF 诊所的 35 名患者中采集尿液样本。如果患者射血分数<45%且至少服用两种疾病修正 HF 药物，则将其纳入研究。如果患者在就诊前 3 个月内因 HF 住院，则将其排除在外。这些样本被送往 HPLC-MS 进行检测，以检测为该患者开具的所有 HF 药物。这些患者的完全依从率高达 89%，94%的患者对治疗（至少检测到一种 HF 药物）部分依从（至少检测到一种 HF 药物）。该分析还表明，盐皮质激素受体拮抗剂是处方最少（67%）和依从性最差（75%）的药物类别。
该分析揭示了慢性 HF 患者对疾病修正治疗的依从率出人意料地高，并强调了我们大多数“总体”治疗不足可能是由于未开具处方而不是未服用药物所致。使用 HPLC-MS 检测尿液中疾病修正 HF 药物的代谢物是可行的，并且是专科 HF 服务的有用补充。目前，治疗失败和未服用治疗之间的区别并不总是很清楚，这一点很重要，因为调查和潜在的解决方案是不同的。前者需要启动额外的治疗，并考虑额外的诊断，而后者则需要了解导致依从性差的原因的策略，并共同努力改善这一点：错误的策略将是无效的。
