Sepehrvand Nariman, Nabipoor Majid, Youngson Erik, McAlister Finlay A, Ezekowitz Justin A
Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada.
J Card Fail. 2023 May;29(5):719-729. doi: 10.1016/j.cardfail.2023.01.005. Epub 2023 Feb 7.
Quadruple therapy is recommended for the management of patients with heart failure (HF) and reduced ejection fraction (HFrEF). In order to provide background and identify barriers to quadruple therapy, in this study, the aim was to explore the time to initiation of triple therapy in a population-based cohort of patients with de novo HF.
Adult patients with de novo hospital or emergency department (ED) diagnosis of HF between April 1, 2008, and March 31, 2018, in Alberta, Canada, were included and were linked to echocardiography data to identify patients with HFrEF (EF ≤ 40%). Any treatment with angiotensin-converting enzyme inhibitors/ angiotensin receptor blockers/ angiotensin receptor neprilysin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists was captured if prescribed for ≥ 28 days and filled at least once during the 12 months after the index episode.
Among 14,092 patients with de novo HF and available echocardiography data, 54.9% had HFrEF. By 1 year after diagnosis, of those in the HFrEF cohort, 9.5% had received no therapy, 27.5% monotherapy, 41.6% dual therapy, and 21.4% triple therapy. The median (interquartile range) of time to mono-, dual- and triple therapy in patients with HFrEF were 1 (0, 26), 8 (0, 44), and 14 (0, 52) days, respectively. Patients who received triple therapy were younger, more likely to be male and to have higher frequencies of coronary artery disease, higher glomerular filtration rates and lower left ventricular ejection fraction levels compared to their counterparts. Patients with triple therapy had lower rates of clinical outcomes compared to those on no, mono or dual therapy (adjusted hazard ratio 0.15, 95% confidence interval 0.13, 0.17 for the composite outcome of death, hospitalization due to HF, or ED visit due to HF).
Despite guideline recommendations, triple therapy is underused and is slowly deployed in patients with HFrEF, even after hospitalization and ED presentation.
对于射血分数降低的心力衰竭（HFrEF）患者，推荐采用四联疗法进行治疗。为了提供背景信息并确定四联疗法的障碍，在本研究中，目的是探讨在一个基于人群的初发HFrEF患者队列中开始三联疗法的时间。
纳入2008年4月1日至2018年3月31日期间在加拿大艾伯塔省首次因心力衰竭在医院或急诊科确诊的成年患者，并将其与超声心动图数据相关联，以识别HFrEF（射血分数≤40%）患者。如果血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂/血管紧张素受体脑啡肽酶抑制剂、β受体阻滞剂和盐皮质激素受体拮抗剂的任何治疗处方持续≥28天且在索引事件后的12个月内至少配药一次，则予以记录。
在14092例初发心力衰竭且有可用超声心动图数据的患者中，54.9%患有HFrEF。在HFrEF队列中，到诊断后1年时，9.5%的患者未接受任何治疗，27.5%接受单一疗法，41.6%接受双联疗法，21.4%接受三联疗法。HFrEF患者开始单一、双联和三联疗法的时间中位数（四分位间距）分别为1（0，26）天、8（0，44）天和14（0，52）天。与未接受治疗、单一疗法或双联疗法的患者相比，接受三联疗法的患者更年轻，男性比例更高，冠状动脉疾病发生率更高，肾小球滤过率更高，左心室射血分数水平更低。与未接受治疗、单一疗法或双联疗法的患者相比，接受三联疗法的患者临床结局发生率更低（对于死亡、因心力衰竭住院或因心力衰竭就诊的复合结局，调整后的风险比为0.15，95%置信区间为0.13，0.17）。
尽管有指南推荐，但三联疗法的使用不足，在HFrEF患者中应用缓慢，即使在住院和急诊科就诊后也是如此。
