Driscoll Andrea, Meagher Sharon, Kennedy Rhoda, Currey Judy
J Cardiovasc Nurs. 2024;39(5):417-426. doi: 10.1097/JCN.0000000000001068. Epub 2024 Jan 16.
Prescribing of recommended medications for heart failure (HF) is suboptimal, leaving patients at a high risk of death or rehospitalization post discharge. Nurse-led titration (NLT) clinics are one strategy that could potentially improve the prescription of these medications.
The aim of this article was to determine the effect of NLT clinics on all-cause mortality, all-cause or HF rehospitalizations, and adverse effects in patients with HF.
We searched MEDLINE, EMBASE, Cochrane CENTRAL, International Clinical Trials Registry Platform, and ClinicalTrials.gov to identify randomized controlled trials comparing NLT of β-blocking agents, angiotensin receptor-neprilysin inhibitors, angiotensin-converting enzyme inhibitors, and/or angiotensin receptor blockers to optimization by another health professional in patients with HF. We used the fixed-effects Mantel-Haenszel method or meta-analyses. We assessed heterogeneity between studies using χ 2 and I2 .
Eight studies with 2025 participants were included. Participants in the NLT group experienced a lower rate of all-cause rehospitalizations (relative risk, 0.76, 95% confidence interval, 0.68-0.85; moderate quality of evidence) and less HF-related rehospitalizations (relative risk, 0.47; 95% confidence interval, 0.33-0.66; high quality of evidence) compared with the usual care group. All-cause mortality was lower in the NLT group (relative risk, 0.67; 95% confidence interval, 0.48-0.92; moderate quality of evidence) compared with the usual care group. Authors of one study reported no adverse events, and another study found one adverse event.
This meta-analysis indicates that NLT clinics may improve optimization of guideline-recommended medications with the potential to reduce rehospitalization and improve survival in a cohort of patients known for their poor outcomes.
心力衰竭（HF）推荐药物的处方情况并不理想，这使得患者出院后面临较高的死亡或再次住院风险。由护士主导的滴定（NLT）诊所是一种有可能改善这些药物处方情况的策略。
本文旨在确定NLT诊所在HF患者全因死亡率、全因或HF再次住院率以及不良反应方面的影响。
我们检索了MEDLINE、EMBASE、Cochrane CENTRAL、国际临床试验注册平台和ClinicalTrials.gov，以识别比较HF患者中β受体阻滞剂、血管紧张素受体脑啡肽酶抑制剂、血管紧张素转换酶抑制剂和/或血管紧张素受体阻滞剂的NLT与由其他医疗专业人员进行优化的随机对照试验。我们使用固定效应Mantel-Haenszel方法或进行荟萃分析。我们使用χ2和I2评估研究之间的异质性。
纳入了8项研究，共2025名参与者。与常规护理组相比，NLT组参与者的全因再次住院率较低（相对风险，0.76；95%置信区间，0.68 - 0.85；证据质量中等），且HF相关再次住院率较低（相对风险，0.47；95%置信区间，0.33 - 0.66；证据质量高）。与常规护理组相比，NLT组的全因死亡率较低（相对风险，0.67；95%置信区间，0.48 - 0.92；证据质量中等）。一项研究的作者报告未发生不良事件，另一项研究发现了1例不良事件。
这项荟萃分析表明，NLT诊所可能会改善指南推荐药物的优化情况，有可能降低已知预后较差的一组患者的再次住院率并提高生存率。
