University of Oxford, Oxford, UK
Arxx Therapeutics, Oslo, Norway.
Open Heart. 2021 Oct;8(2). doi: 10.1136/openhrt-2021-001630.
To assess current management practice of heart failure with reduced ejection fraction (HFrEF) in multinational primary care (PC) and determine whether N-terminal-pro-B-type natriuretic peptide (NT-pro-BNP)-guided referral of HFrEF patients from PC to a cardiologist could improve care, defined as adherence to European Society of Cardiology (ESC) guideline-recommended pharmacotherapy.
PRospective Evaluation of natriuretic peptide-based reFERral of patients with chronic HF in PC (PREFER) study enrolled HFrEF patients from PC considered clinically stable and those with NT-pro-BNP ≥600 pg/mL were referred to a cardiologist for optimisation of HF treatment. The primary outcome of adherence to ESC HF guidelines after referral to specialist was assessed at the second visit within 4 weeks of cardiologist's referral and no later than 6 months after the baseline visit. Based on futility interim analysis, the study was terminated early.
In total, 1415 HFrEF patients from 223 PCs from 18 countries in Europe were enrolled. Of these, 1324 (96.9%) were considered clinically stable and 920 (65.0%) had NT-pro-BNP ≥600 pg/mL (mean: 2631 pg/mL). In total, 861 (60.8%) patients fulfilled both criteria and were referred to a cardiologist. Before cardiologist consultation, 10.1% of patients were on ESC guideline-recommended HFrEF medications and 2.7% were on recommended dosages of HFrEF medication (defined as ≥50% of ESC guideline-recommended dose). Postreferral, prescribed HFrEF drugs remained largely unchanged except for an increase in diuretics (+4.6%) and mineralocorticoid receptor antagonists (+7.9%). No significant increase in patients' adherence to guideline-defined drug combinations (11.2% post-referral vs 10.1% baseline) or drug combinations and dosages (3.3% postreferral vs 2.7% baseline) was observed after cardiologist consultation.
PREFER demonstrates substantial suboptimal treatment of HFrEF patients in the real world. Referral of patients with elevated NT-pro-BNP levels from PC to cardiologist did not result in meaningful treatment optimisation for treatments with known mortality and morbidity benefit.
评估多国初级保健（PC）中射血分数降低的心力衰竭（HFrEF）的当前管理实践，并确定是否可以通过将 PC 中的 HFrEF 患者的 N-末端 B 型利钠肽前体（NT-pro-BNP）指导转诊至心脏病专家，改善治疗效果，该治疗效果定义为是否遵循欧洲心脏病学会（ESC）指南推荐的药物治疗。
在基层医疗中以利钠肽为基础的慢性心力衰竭患者的前瞻性评估（PREFER）研究中，纳入了 PC 中被认为临床稳定的 HFrEF 患者，并且那些 NT-pro-BNP≥600pg/mL 的患者被转诊至心脏病专家处，以优化 HF 治疗。在转诊至专科医生后 4 周内的第二次就诊时评估接受专科医生治疗后，对 ESC HF 指南的遵循情况作为主要结局，最晚不超过基线就诊后 6 个月。根据无效性中期分析，研究提前终止。
共有来自欧洲 18 个国家的 223 家 PC 的 1415 名 HFrEF 患者入组。其中，1324 名（96.9%）患者被认为临床稳定，920 名（65.0%）患者 NT-pro-BNP≥600pg/mL（平均：2631pg/mL）。共有 861 名（60.8%）患者同时满足这两个标准，并被转诊至心脏病专家处。在接受心脏病专家咨询之前，仅有 10.1%的患者接受 ESC 指南推荐的 HFrEF 药物治疗，2.7%的患者接受了 HFrEF 药物的推荐剂量（定义为 ESC 指南推荐剂量的≥50%）。转诊后，除利尿剂（+4.6%）和盐皮质激素受体拮抗剂（+7.9%）的使用有所增加外，HFREF 药物的处方基本保持不变。在接受心脏病专家咨询后，并未观察到患者对指南定义的药物联合治疗（转诊后 11.2%比基线时 10.1%）或药物联合和剂量（转诊后 3.3%比基线时 2.7%）的依从性有显著增加。
PREFER 研究表明，在现实世界中，HFREF 患者的治疗存在很大的不合理之处。将 NT-pro-BNP 水平升高的患者从 PC 转诊至心脏病专家，并未导致治疗效果的显著优化，这些治疗方法具有已知的死亡率和发病率获益。
