Division of Health Systems Science, Department of Medicine, Chan Medical School, University of Massachusetts, Worcester; Division of Geriatric Medicine, Department of Medicine, Chan Medical School, University of Massachusetts, Worcester; Department of Population and Quantitative Health Sciences, Chan Medical School, University of Massachusetts, Worcester.
Division of Health Systems Science, Department of Medicine, Chan Medical School, University of Massachusetts, Worcester; Division of Geriatric Medicine, Department of Medicine, Chan Medical School, University of Massachusetts, Worcester; Department of Population and Quantitative Health Sciences, Chan Medical School, University of Massachusetts, Worcester.
Am J Med. 2022 Dec;135(12):1468-1477. doi: 10.1016/j.amjmed.2022.08.010. Epub 2022 Sep 2.
Current clinical practice guidelines recommend routine kidney function and serum potassium testing within 30 days of initiating angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) therapy. However, evidence is lacking on whether routine follow-up testing reduces therapy-related adverse events in adults with heart failure and if multimorbidity influences the association between laboratory testing and these adverse events.
We conducted a retrospective cohort study among adults with heart failure from 4 US integrated health care delivery systems. Multimorbidity was defined using counts of chronic conditions. Patients with outpatient serum creatinine and potassium tests in the 30 days after starting ACEI or ARB therapy were matched 1:1 to patients without follow-up tests. We evaluated the association of follow-up testing with 30-day all-cause mortality and hospitalization with acute kidney injury or hyperkalemia using Cox regression.
We identified 3629 matched adults with heart failure initiating ACEI or ARB therapy between January 1, 2005, and December 31, 2012. Follow-up testing was not significantly associated with 30-day all-cause mortality (adjusted hazard ratio [aHR] 0.45, 95% confidence interval [CI] 0.14; 1.39) and hospitalization with hyperkalemia (aHR 0.73, 95% CI, 0.33; 1.61). However, follow-up testing was significantly associated with hospitalization with acute kidney injury (aHR, 1.40, 95% CI, 1.01; 1.94). Interaction between multimorbidity burden and follow-up testing was not statistically significant in any of the outcome models examined.
Routine laboratory monitoring after ACEI or ARB therapy initiation was not associated with risk of 30-day all-cause mortality or hospitalization with hyperkalemia across the spectrum of multimorbidity burden in a cohort of patients with heart failure.
目前的临床实践指南建议在开始使用血管紧张素转换酶抑制剂（ACEI）或血管紧张素 II 受体阻滞剂（ARB）治疗后 30 天内常规检查肾功能和血清钾。然而，目前尚缺乏证据表明常规随访检查是否能降低心力衰竭患者接受治疗相关不良事件的风险，以及是否存在多种合并症会影响实验室检查与这些不良事件之间的关联。
我们对来自 4 个美国综合医疗服务提供系统的心力衰竭成年患者进行了一项回顾性队列研究。采用慢性疾病的数量来定义多种合并症。在开始使用 ACEI 或 ARB 治疗后 30 天内进行门诊血清肌酐和钾检测的患者与未进行后续检测的患者进行 1:1 匹配。我们使用 Cox 回归评估了后续检测与 30 天全因死亡率和因急性肾损伤或高钾血症住院的关联。
我们确定了 2005 年 1 月 1 日至 2012 年 12 月 31 日期间开始使用 ACEI 或 ARB 治疗的 3629 例心力衰竭成年患者进行了匹配。后续检测与 30 天全因死亡率无显著相关性（校正后的危险比[aHR]0.45，95%置信区间[CI]0.14；1.39）和因高钾血症住院（aHR0.73，95%CI0.33；1.61）。然而，后续检测与因急性肾损伤住院显著相关（aHR1.40，95%CI1.01；1.94）。在我们检查的任何结局模型中，多种合并症负担与后续检测之间的交互作用均无统计学意义。
在心力衰竭患者队列中，ACEI 或 ARB 治疗后开始进行常规实验室监测与 30 天全因死亡率或因高钾血症住院的风险无关，无论多种合并症负担如何。
