心力衰竭中多病共治与指南导向的优化药物治疗：GUIDE-IT 试验。
Polypharmacy and Optimization of Guideline-Directed Medical Therapy in Heart Failure: The GUIDE-IT Trial.
机构信息
Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA.
Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
出版信息
JACC Heart Fail. 2023 Nov;11(11):1507-1517. doi: 10.1016/j.jchf.2023.03.007. Epub 2023 Apr 26.
BACKGROUND
Polypharmacy is common among patients with heart failure with reduced ejection fraction (HFrEF). However, its impact on the use of optimal guideline-directed medical therapy (GDMT) is not well established.
OBJECTIVES
This study sought to evaluate the association between polypharmacy and odds of receiving optimal GDMT over time among patients with HFrEF.
METHODS
The authors conducted a post hoc analysis of the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment) trial. Polypharmacy was defined as receiving ≥5 medications (excluding HFrEF GDMT) at baseline. The outcome of interest was optimal triple therapy GDMT (concurrent administration of a renin-angiotensin-aldosterone blocker and beta-blocker at 50% of the target dose and a mineralocorticoid receptor antagonist at any dose) achieved over the 12-month follow-up. Multivariable adjusted mixed-effect logistic regression models with multiplicative interaction terms (time × polypharmacy) were constructed to evaluate how polypharmacy at baseline modified the odds of achieving optimal GDMT on follow-up.
RESULTS
The study included 891 participants with HFrEF. The median number of non-GDMT medications at baseline was 4 (IQR: 3-6), with 414 (46.5%) prescribed ≥5 and identified as being on polypharmacy. The proportion of participants who achieved optimal GDMT at the end of the 12-month follow-up was lower with vs without polypharmacy at baseline (15% vs 19%, respectively). In adjusted mixed models, the odds of achieving optimal GDMT over time were modified by baseline polypharmacy status (P for interaction < 0.001). Patients without polypharmacy at baseline had increased odds of achieving GDMT (OR: 1.16 [95% CI: 1.12-1.21] per 1-month increase; P < 0.001) but not patients with polypharmacy (OR: 1.01 [95% CI: 0.96-1.06)] per 1-month increase).
CONCLUSIONS
Patients with HFrEF who are on non-GDMT polypharmacy have lower odds of achieving optimal GDMT on follow-up.
背景
射血分数降低的心力衰竭（HFrEF）患者常合并多种药物治疗。然而，其对最佳指南指导的药物治疗（GDMT）的应用的影响尚不清楚。
目的
本研究旨在评估射血分数降低的心力衰竭患者中，随着时间的推移，合并多种药物治疗与接受最佳 GDMT 的几率之间的关系。
方法
作者对 GUIDE-IT（使用生物标志物强化治疗指导循证治疗）试验进行了事后分析。合并多种药物治疗定义为基线时接受≥5 种药物治疗（不包括 HFrEF GDMT）。主要结局为 12 个月随访期间接受最佳三联 GDMT（同时给予血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂和β受体阻滞剂，目标剂量的 50%，以及任何剂量的盐皮质激素受体拮抗剂）。构建了多变量调整的混合效应逻辑回归模型，并加入了乘法交互项（时间×合并多种药物治疗），以评估基线时合并多种药物治疗如何改变随访时接受最佳 GDMT 的几率。
结果
研究纳入了 891 例 HFrEF 患者。基线时非 GDMT 药物的中位数为 4 种（IQR：3-6），414 例（46.5%）患者接受≥5 种药物治疗，被认为是合并多种药物治疗。与基线时无合并多种药物治疗的患者相比，在 12 个月随访结束时接受最佳 GDMT 的患者比例较低（分别为 15%和 19%）。在调整后的混合模型中，基线合并多种药物治疗状态改变了接受最佳 GDMT 的几率（交互作用 P 值<0.001）。基线时无合并多种药物治疗的患者接受 GDMT 的几率增加（每增加 1 个月的 OR：1.16[95%CI：1.12-1.21]；P<0.001），但基线时合并多种药物治疗的患者接受 GDMT 的几率没有增加（每增加 1 个月的 OR：1.01[95%CI：0.96-1.06]）。
结论
接受非 GDMT 合并多种药物治疗的射血分数降低的心力衰竭患者，在随访期间接受最佳 GDMT 的几率较低。
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