Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia.
Griffith University, Nathan, Queensland, Australia.
BMJ Open. 2022 May 4;12(5):e057856. doi: 10.1136/bmjopen-2021-057856.
This study sought whether higher risk patients with coronary heart disease (CHD) benefit more from intensive disease management.
Longitudinal cohort study.
State-wide public hospitals (Queensland, Australia).
This longitudinal study included 20 426 patients hospitalised in 2010 with CHD as the principal diagnosis. Patients were followed-up for 5 years.
The primary outcome was days alive and out of hospital (DAOH) within 5 years of hospital discharge. Secondary outcomes included all-cause readmission and all-cause mortality. A previously developed and validated risk score (PEGASUS-TIMI54) was used to estimate the risk of secondary events. Data on sociodemography, comorbidity, interventions and medications were also collected.
High-risk patients (n=6573, risk score ≥6) had fewer DAOH (∆=-142 days (95% CI: -152 to -131)), and were more likely to readmit or die (all p<0.001) than their low-risk counterparts (n=13 367, risk score <6). Compared with patients who were never prescribed a medication, those who consumed maximal dose of betablockers (∆=39 days (95% CI: 11 to 67)), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (∆=74 days (95% CI: 49 to 99)) or statins (∆=109 days (95% CI: 90 to 128)) had significantly greater DAOH. Patients who received percutaneous coronary intervention (∆=99 days (95% CI: 81 to 116)) or coronary artery bypass grafting (∆=120 days (95% CI: 92 to 148)) also had significantly greater DAOH than those who did not. The effect sizes of these therapies were significantly greater in high-risk patients, compared with low-risk patients (interaction p<0.001). Analysis of secondary outcomes also found significant interaction between both medical and interventional therapies with readmission and death, implicating greater benefits for high-risk patients.
CHD patients can be effectively risk-stratified, and use of this information for a risk-guided strategy to prioritise high-risk patients may maximise benefits from additional resources spent on intensive disease management.
本研究旨在探讨冠心病（CHD）高危患者是否从强化疾病管理中获益更多。
纵向队列研究。
澳大利亚昆士兰州全州公立医院。
本纵向研究纳入了 2010 年因 CHD 为主诊断住院的 20426 例患者。患者在出院后随访 5 年。
主要结局是出院后 5 年内的存活天数和离院天数（DAOH）。次要结局包括全因再入院和全因死亡率。使用先前开发和验证的风险评分（PEGASUS-TIMI54）来估计次要事件的风险。还收集了社会人口统计学、合并症、干预措施和药物使用的数据。
高危患者（n=6573，风险评分≥6）的 DAOH 更少（∆=-142 天（95%CI：-152 至-131）），且更有可能再入院或死亡（均<0.001），而低危患者（n=13367，风险评分<6）则不然。与从未服用过药物的患者相比，服用最大剂量β受体阻滞剂（∆=39 天（95%CI：11 至 67））、血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂（∆=74 天（95%CI：49 至 99））或他汀类药物（∆=109 天（95%CI：90 至 128））的患者的 DAOH 明显更长。接受经皮冠状动脉介入治疗（∆=99 天（95%CI：81 至 116））或冠状动脉旁路移植术（∆=120 天（95%CI：92 至 148））的患者的 DAOH 也明显长于未接受治疗的患者。与低危患者相比，这些治疗方法的效果在高危患者中更为显著（交互作用 p<0.001）。对次要结局的分析还发现，药物和介入治疗与再入院和死亡之间存在显著的交互作用，这意味着高危患者的获益更大。
可以对 CHD 患者进行有效的风险分层，使用该信息制定风险指导策略，优先考虑高危患者，可能会使强化疾病管理所花费的额外资源得到最大程度的利用，从而使高危患者获益最大化。
