模拟指南指导下的药物治疗出院医嘱对冠状动脉旁路移植术后 15 年生存率的影响试验

Emulated Trial for Discharge Prescription of Guideline-Directed Medical Therapy and 15-Year Survival After Coronary Artery Bypass Graft Surgery.

机构信息

Department of Cardiothoracic Surgery, Assuta Hospital, Tel Aviv, affiliated to the Faculty of Heath Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel.

Research Center for Public Health, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan, Israel; Department of Epidemiology and Preventive Medicine, Faculty of Medicine, School of Public Health, Tel Aviv University, Tel Aviv, Israel.

出版信息

Mayo Clin Proc. 2024 May;99(5):766-779. doi: 10.1016/j.mayocp.2023.06.022. Epub 2024 Mar 7.

DOI:10.1016/j.mayocp.2023.06.022

PMID:38456874

Abstract

OBJECTIVES

To explore admission and discharge prescription rates of guideline-directed medical therapy (GDMT), defined as aggregate antiplatelet agents, statins, and β-blockers, after coronary artery bypass graft (CABG) surgery and to reveal its association with long-term survival.

PATIENTS AND METHODS

This is a prospective cohort study-based emulated trial of patients undergoing elective or semi-elective isolated CABG surgery in 7 cardiothoracic units in Israel from January 1, 2004, to December 31, 2007, and followed up until December 31, 2020, for all-cause mortality.

RESULTS

Only 59.2% of 968 patients (n=573) were discharged on GDMT after CABG surgery. Admission GDMT use conferred a 7 times greater likelihood of discharge GDMT prescription (odds ratio, 7.07; 95% CI, 5.04 to 9.91; P<.001), with no sex differences observed. After applying inverse probability of treatment weighting, baseline characteristics were well balanced between groups. During a median follow-up of 13.7 years, a Cox regression model with propensity score-adjusted inverse probability of treatment weighting revealed lower mortality in patients with discharge GDMT prescription who underwent CABG surgery than in their counterparts (hazard ratio, 0.75; 95% CI, 0.60 to 0.93; P=.008).

CONCLUSION

The use of aggregate GDMT before surgery conferred a greater likelihood of GDMT prescription upon discharge, which, in turn, is associated with better long-term survival. Educational efforts of pertinent medical professionals are needed to minimize preventive treatment gaps.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00356863.

摘要

目的

探讨冠状动脉旁路移植术（CABG）后指南指导的药物治疗（GDMT），即抗血小板药物、他汀类药物和β受体阻滞剂的入院和出院处方率，并揭示其与长期生存的关系。

患者和方法

这是一项基于前瞻性队列研究的模拟试验，纳入了 2004 年 1 月 1 日至 2007 年 12 月 31 日期间在以色列 7 个心胸外科单位接受择期或半择期单纯 CABG 手术的患者，并随访至 2020 年 12 月 31 日，以评估全因死亡率。

结果

968 例患者（n=573）中仅 59.2%在 CABG 手术后接受 GDMT 出院治疗。入院 GDMT 使用使出院 GDMT 处方的可能性增加了 7 倍（优势比，7.07；95%置信区间，5.04 至 9.91；P<.001），且未观察到性别差异。应用逆概率治疗加权后，两组间的基线特征得到了很好的平衡。在中位随访 13.7 年期间，使用倾向评分调整逆概率治疗加权的 Cox 回归模型显示，与未接受 GDMT 处方的 CABG 手术患者相比，接受 GDMT 处方的患者死亡率更低（风险比，0.75；95%置信区间，0.60 至 0.93；P=.008）。