Rastogi Tripti, Duarte Kevin, Huttin Olivier, Roubille François, Girerd Nicolas
Centre d'Investigation Clinique Pierre Drouin-INSERM-CHRU de Nancy, Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, 54000 Nancy, France.
Cardiology Department, CHU de Montpellier, PhyMedExp, Université de Montpellier, INSERM, CNRS, 34090 Montpellier, France.
J Clin Med. 2022 Dec 22;12(1):99. doi: 10.3390/jcm12010099.
A substantial proportion of patients with heart failure (HF) receive suboptimal guideline-recommended therapy. We aimed to identify the factors leading to suboptimal drug prescription in HF and according to HF phenotypes. This retrospective, single-centre observational cohort study included 702 patients admitted for worsening HF (HF with a reduced ejection fraction [HFrEF], n = 198; HF with a mildly reduced EF [HFmrEF], n = 122; and HF with a preserved EF [HFpEF], n = 382). A score based on the prescription and dose percentage of ACEi/ARBs, β-blockers, and MRAs at discharge was calculated (a total score ranging from zero to six). Approximately 70% of patients received ACEi/ARBs/ARNi, 80% of patients received β-blockers, and 20% received MRAs. The mean HF drug dose was approximately 50% of the recommended dose, irrespective of the HF phenotype. Ischaemic heart disease was associated with a higher prescription score (ranging from 0.4 to 1) compared to no history of ischaemic heart disease, irrespective of the left ventricular EF (LVEF) level. A lower prescription score was associated with older age and male sex in HFrEF and diabetes in HFmrEF. The overall ability of the models to predict the optimal drug dose, including key HF variables (including natriuretic peptides at admission), was poor (R2 < 0.25). A higher prescription score was associated with a lower risk of re-hospitalization and death (HR: 0.75 (0.57−0.97), p = 0.03), irrespective of phenotype (p-interaction = 0.41). Despite very different HF management guidelines according to LVEF, the prescription pattern of HF drugs is poorly related to LVEF and clinical characteristics, thus suggesting that physician-driven factors may be involved in the setting of therapeutic inertia. It may also be related to drug intolerance or clinical stability that is not predicted by the patients’ profiles.
相当一部分心力衰竭（HF）患者接受的治疗未达指南推荐的最佳标准。我们旨在确定导致HF患者药物处方未达最佳标准的因素，并根据HF表型进行分析。这项回顾性、单中心观察性队列研究纳入了702例因HF病情恶化入院的患者（射血分数降低的HF [HFrEF]，n = 198；射血分数轻度降低的HF [HFmrEF]，n = 122；射血分数保留的HF [HFpEF]，n = 382）。计算出院时基于ACEi/ARBs、β受体阻滞剂和MRAs的处方及剂量百分比的评分（总分范围为0至6分）。约70%的患者接受了ACEi/ARBs/ARNi，80%的患者接受了β受体阻滞剂，20%的患者接受了MRAs。无论HF表型如何，HF药物的平均剂量约为推荐剂量的50%。与无缺血性心脏病病史相比，缺血性心脏病与更高的处方评分相关（范围为0.4至1），无论左心室射血分数（LVEF）水平如何。在HFrEF中，较低的处方评分与老年和男性性别相关，在HFmrEF中与糖尿病相关。包括关键HF变量（包括入院时的利钠肽）在内的模型预测最佳药物剂量的总体能力较差（R2 < 0.25）。较高的处方评分与再住院和死亡风险较低相关（HR：0.75（0.57 - 0.97），p = 0.03），无论表型如何（p交互作用 = 0.41）。尽管根据LVEF制定了非常不同的HF管理指南，但HF药物的处方模式与LVEF和临床特征的相关性较差，因此提示医生驱动的因素可能参与了治疗惰性的形成。这也可能与药物不耐受或患者特征未预测到的临床稳定性有关。
