衰弱与血管紧张素受体脑啡肽酶抑制剂用于射血分数降低的心力衰竭
Frailty and uptake of angiotensin receptor neprilysin inhibitor for heart failure with reduced ejection fraction.
机构信息
Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.
出版信息
J Am Geriatr Soc. 2023 Oct;71(10):3110-3121. doi: 10.1111/jgs.18481. Epub 2023 Jun 22.
BACKGROUND
Frail older adults may be less likely to receive guideline-directed medical therapy (GDMT)-renin-angiotensin blockers, beta-blockers, and mineralocorticoid receptor antagonists-for heart failure with reduced ejection fraction (HFrEF). We aimed to examine the uptake of angiotensin receptor neprilysin inhibitor (ARNI) and GDMT in frail older adults with HFrEF.
METHODS
Using 2015-2019 Medicare data, we estimated the proportion of beneficiaries with HFrEF receiving ARNI and GDMT each year by frailty status, defined by a claims-based frailty index. Logistic regression was used to identify clinical characteristics associated with ARNI initiation. Cox proportional hazards regression was used to examine the association of GDMT use in 2015 and death or heart failure hospitalization in 2016-2019.
RESULTS
Among 147,506-180,386 beneficiaries with HFrEF (mean age: 77 years; 27% women; 42.6-49.1% frail) in 2015-2019, the proportion of patients receiving ARNI increased in both non-frail (0.4%-16.4%) and frail (0.3%-13.7%) patients (p for yearly-trend-by-frailty = 0.970). Among those not receiving a renin-angiotensin system blocker, patients with age ≥ 85 years (odds ratio [95% CI], 0.89 [0.80-0.99]), dementia (0.88 [0.81-0.96]), and frailty (0.87 [0.81-0.94]) were less likely to initiate ARNI. The proportion of patients receiving all 3 GDMT classes increased in non-frail patients (22.0%-27.0%) but changed minimally in frail patients (19.6%-21.8%). Regardless of frailty status, treatment with at least 1 class of GDMT was associated with lower death or heart failure hospitalization than no GDMT medications (hazard ratio [95% CI], 0.94 [0.91-0.97], 0.92 [0.89-0.94], 0.94 [0.91-0.97] for 1, 2, and 3 classes, respectively).
CONCLUSIONS
Our results suggest an evidence-practice gap in the use of ARNI and GDMT in Medicare beneficiaries with HFrEF, particularly those with frailty. Efforts to narrow this gap are needed to reduce the burden of HFrEF in older adults.
背景
衰弱的老年患者接受指南指导的医学治疗（GDMT）-肾素-血管紧张素阻滞剂、β受体阻滞剂和盐皮质激素受体拮抗剂-的可能性可能较低，用于射血分数降低的心力衰竭（HFrEF）。我们旨在研究衰弱的老年 HFrEF 患者接受血管紧张素受体脑啡肽酶抑制剂（ARNI）和 GDMT 的情况。
方法
使用 2015-2019 年医疗保险数据，我们根据基于索赔的虚弱指数，每年估计 HFrEF 受益人的 ARNI 和 GDMT 接受率。使用逻辑回归确定与 ARNI 起始相关的临床特征。使用 Cox 比例风险回归分析 2015 年 GDMT 的使用与 2016-2019 年死亡或心力衰竭住院的相关性。
结果
在 2015-2019 年 147506-180386 名 HFrEF 患者（平均年龄：77 岁；27%为女性；42.6-49.1%为虚弱）中，非虚弱（0.4%-16.4%）和虚弱（0.3%-13.7%）患者接受 ARNI 的比例均有所增加（按虚弱程度划分的年度趋势，p=0.970）。在未接受肾素-血管紧张素系统阻滞剂的患者中，年龄≥85 岁（比值比[95%CI]，0.89[0.80-0.99]）、痴呆（0.88[0.81-0.96]）和虚弱（0.87[0.81-0.94]）的患者不太可能开始使用 ARNI。非虚弱患者接受所有 3 类 GDMT 的比例增加（22.0%-27.0%），但虚弱患者变化不大（19.6%-21.8%）。无论虚弱程度如何，至少使用 1 类 GDMT 治疗与未使用 GDMT 药物相比，死亡或心力衰竭住院率较低（危险比[95%CI]，0.94[0.91-0.97]，0.92[0.89-0.94]，0.94[0.91-0.97]，分别为 1、2 和 3 类）。
结论
我们的结果表明，医疗保险 HFrEF 受益人的 ARNI 和 GDMT 使用存在证据-实践差距，特别是在虚弱的患者中。需要努力缩小这一差距，以减轻老年人心力衰竭的负担。
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