[肾功能对射血分数降低的心力衰竭患者药物治疗优化及死亡率的影响]

[The effect of kidney function on the optimization of medical therapy and on mortality in heart failure with reduced ejection fraction].

作者信息

Bánfi-Bacsárdi Fanni, Vámos Máté, Majoros Zsuzsanna, Török Gábor, Pilecky Dávid, Duray Gábor Zoltán, Kiss Róbert Gábor, Nyolczas Noémi, Muk Balázs

机构信息

1 Észak-Pesti Centrumkórház - Honvédkórház, Kardiológiai Osztály Budapest Magyarország.

2 Gottsegen György Országos Kardiovaszkuláris Intézet, Felnőtt Kardiológiai Osztály Budapest, Haller u. 29., 1096 Magyarország.

出版信息

Orv Hetil. 2023 Sep 3;164(35):1387-1396. doi: 10.1556/650.2023.32836.

DOI:10.1556/650.2023.32836

PMID:37660348

Abstract

INTRODUCTION

Renal dysfunction is a main limiting factor of applying and up-titrating guideline-directed medical therapy (GDMT) among patients with heart failure with reduced ejection fraction (HFrEF).

OBJECTIVE

Our retrospective monocentric observational study aimed to analyse the application ratio of combined neurohormonal antagonist therapy (RASi: ACEI/ARB/ARNI + βB + MRA) and 12-month all-cause mortality differences in terms of renal dysfunction among HFrEF patients hospitalized for heart failure.

METHOD

We retrospectively analysed the cohort of consecutive HFrEF patients, hospitalized at the Heart Failure Unit of our tertiary cardiological centre in 2019-2021. The application ratio of discharge triple therapy (TT) in five groups established on admission eGFR parameters, representing severity of renal dysfunction (eGFR≥90, eGFR = 60-89, eGFR = 45-59, eGFR = 30-44, eGFR<30 ml/min/1.73 m2) was investigated with chi-square test, while 12-month mortality differences were analysed with Kaplan-Meier method and log-rank test.

RESULTS

257 patients were included. Median eGFR was 57 (39-75) ml/min/1.73 m2, 54% of patients had eGFR<60 ml/min/1.73 m2. The proportion of patients in eGFR≥90, 60-89, 45-59, 30-44, <30 ml/min/1.73 m2 subgroups was 12%, 34%, 18%, 21%, 15%, respectively. 2% of patients were on dialysis. Even though the application rate of TT was notably high (77%) in the total cohort, more severe renal dysfunction led to a significantly lower implementation rate of TT (94%, 86%, 91%, 70%, 34%; p<0.0001): the application rate of RASi (100%, 98%, 96%, 89%, 50%, p<0.0001), βB (94%, 88%, 96%, 79%, 68%; p = 0.003) and MRA therapy (97%, 99%, 98%, 94%, 82%; p = 0.001) differed significantly. 12-month all-cause mortality was 23% in the whole cohort. Mortality rates were higher in more severe renal dysfunction (3%, 15%, 22%, 31%, 46%; p<0.0001).

CONCLUSION

Even though the proportion of patients on TT in the whole cohort was remarkably high, renal dysfunction led to a significantly lower application ratio of TT, associating with worse survival. Our results highlight that despite renal dysfunction the application of HFrEF cornerstone pharmacotherapy is essential. Orv Hetil. 2023; 164(35): 1387-1396.

摘要

引言

肾功能不全是射血分数降低的心力衰竭（HFrEF）患者应用和滴定指南导向的药物治疗（GDMT）的主要限制因素。

目的

我们的回顾性单中心观察性研究旨在分析合并神经激素拮抗剂治疗（RASi：ACEI/ARB/ARNI + βB + MRA）的应用比例以及因心力衰竭住院的HFrEF患者中肾功能不全患者的12个月全因死亡率差异。

方法

我们回顾性分析了2019年至2021年在我们三级心脏病中心心力衰竭病房住院的连续性HFrEF患者队列。通过卡方检验研究根据入院时估算肾小球滤过率（eGFR）参数确定的五组（代表肾功能不全的严重程度：eGFR≥90、eGFR = 60 - 89、eGFR = 45 - 59、eGFR = 30 - 44、eGFR<30 ml/min/1.73 m²）出院三联疗法（TT）的应用比例，同时采用Kaplan-Meier方法和对数秩检验分析12个月死亡率差异。

结果

纳入257例患者。eGFR中位数为57（39 - 75）ml/min/1.73 m²，54%的患者eGFR<60 ml/min/1.73 m²。eGFR≥90、60 - 89、45 - 59、30 - 44、<30 ml/min/1.73 m²亚组患者的比例分别为12%、34%、18%、21%、15%。2%的患者接受透析治疗。尽管整个队列中TT的应用率显著较高（77%），但更严重的肾功能不全导致TT的实施率显著降低（94%、86%、91%、70% < 34%；p<0.0001）：RASi（100%、98%、96%、89%、50%，p<0.0001）、βB（[94%、88%、96%、79%、68%；p = 0.003]）和MRA治疗（97%、99% < 98%、94% < 82%；p = 0.001）的应用率差异显著。整个队列的12个月全因死亡率为23%。肾功能不全越严重死亡率越高（3%、15%、22%、31%、46%；p<0.0001）。