β受体阻滞剂与老年心力衰竭患者死亡率和再入院率的关系：一项工具变量分析。
Association Between Beta-Blockers and Mortality and Readmission in Older Patients with Heart Failure: an Instrumental Variable Analysis.
机构信息
Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
出版信息
J Gen Intern Med. 2021 Aug;36(8):2361-2369. doi: 10.1007/s11606-021-06901-7. Epub 2021 Jun 7.
BACKGROUND
The demographics of heart failure are changing. The rate of growth of the "older" heart failure population, specifically those ≥ 75, has outpaced that of any other age group. These older patients were underrepresented in the early beta-blocker trials. There are several reasons, including a decreased potential for mortality benefit and increased risk of side effects, why the risk/benefit tradeoff may be different in this population.
OBJECTIVE
We aimed to determine the association between receipt of a beta-blocker after heart failure discharge and early mortality and readmission rates among patients with heart failure and reduced ejection fraction (HFrEF), specifically patients aged 75+.
DESIGN AND PARTICIPANTS
We used 100% Medicare Parts A and B and a random 40% sample of Part D to create a cohort of beneficiaries with ≥ 1 hospitalization for HFrEF between 2008 and 2016 to run an instrumental variable analysis.
MAIN MEASURE
The primary measure was 90-day, all-cause mortality; the secondary measure was 90-day, all-cause readmission.
KEY RESULTS
Using the two-stage least squared methodology, among all HFrEF patients, receipt of a beta-blocker within 30-day of discharge was associated with a - 4.35% (95% CI - 6.27 to - 2.42%, p < 0.001) decrease in 90-day mortality and a - 4.66% (95% CI - 7.40 to - 1.91%, p = 0.001) decrease in 90-day readmission rates. Even among patients ≥ 75 years old, receipt of a beta-blocker at discharge was also associated with a significant decrease in 90-day mortality, - 4.78% (95% CI - 7.19 to - 2.40%, p < 0.001) and 90-day readmissions, - 4.67% (95% CI - 7.89 to - 1.45%, p < 0.001).
CONCLUSION
Patients aged ≥ 75 years who receive a beta-blocker after HFrEF hospitalization have significantly lower 90-day mortality and readmission rates. The magnitude of benefit does not appear to wane with age. Absent a strong contraindication, all patients with HFrEF should attempt beta-blocker therapy at/after hospital discharge, regardless of age.
背景
心力衰竭的人口统计学正在发生变化。“较年长”心力衰竭患者（尤其是≥75 岁的患者）的增长率超过了任何其他年龄组。这些老年患者在早期β受体阻滞剂试验中的代表性不足。由于死亡率获益降低和副作用风险增加等原因，该人群的风险/获益权衡可能有所不同。
目的
我们旨在确定心力衰竭出院后接受β受体阻滞剂治疗与射血分数降低的心力衰竭（HFrEF）患者（特别是≥75 岁的患者）的早期死亡率和再入院率之间的关系。
设计和参与者
我们使用了 100%的医疗保险 A 部分和 B 部分以及随机抽取的 40%的 D 部分，创建了一个在 2008 年至 2016 年期间至少有 1 次因 HFrEF 住院的受益人群队列，以进行工具变量分析。
主要测量指标
主要测量指标为 90 天全因死亡率；次要测量指标为 90 天全因再入院率。
主要结果
使用两阶段最小二乘法，在所有 HFrEF 患者中，出院后 30 天内接受β受体阻滞剂治疗与 90 天死亡率降低 4.35%（95%置信区间：-6.27%至-2.42%，p<0.001）和 90 天再入院率降低 4.66%（95%置信区间：-7.40%至-1.91%，p=0.001）相关。即使在≥75 岁的患者中，出院时接受β受体阻滞剂治疗也与 90 天死亡率显著降低相关，-4.78%（95%置信区间：-7.19%至-2.40%，p<0.001）和 90 天再入院率降低，-4.67%（95%置信区间：-7.89%至-1.45%，p<0.001）。
结论
HFrEF 住院后接受β受体阻滞剂治疗的≥75 岁患者的 90 天死亡率和再入院率显著降低。获益的幅度似乎不会随年龄的增长而减弱。在没有强烈禁忌症的情况下，所有 HFrEF 患者都应尝试在出院时/出院后进行β受体阻滞剂治疗，无论年龄大小。
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