Tang Amber B, Ziaeian Boback, Butler Javed, Yancy Clyde W, Fonarow Gregg C
Department of Medicine, UCLA, Los Angeles, California.
Division of Cardiology, UCLA, Los Angeles, California.
JAMA Cardiol. 2024 Dec 1;9(12):1154-1158. doi: 10.1001/jamacardio.2024.3023.
Guideline-directed medical therapy (GDMT) remains underutilized on a global level, with significant disparities in access to treatment worldwide. The potential global benefits of quadruple therapy on patients with heart failure with reduced ejection fraction (HFrEF) have not yet been estimated.
To assess the projected population-level benefit of optimal GDMT use globally among patients with HFrEF.
DESIGN, SETTING, AND PARTICIPANTS: Estimates for HFrEF prevalence, contraindications to GDMT, treatment rates, and the number needed to treat for all-cause mortality at 12 months were derived from previously published sources. Potential lives saved from optimal implementation of quadruple therapy among patients with HFrEF was calculated globally and a sensitivity analysis was conducted to account for uncertainty in the existing data.
All-cause mortality.
Of an estimated 28.89 million people with HFrEF worldwide, there were 8 235 063 (95% CI, 6 296 020-10 762 972) potentially eligible for but not receiving β-blockers, 20 387 000 (95% CI, 15 867 004-26 184 996) eligible for but not receiving angiotensin receptor-neprilysin inhibitors, 12 223 700 (95% CI, 9 376 895-15 924 973) eligible for but not receiving mineralocorticoid receptor antagonists, and 21 229 170 (95% CI, 16 537 400-27 242 688) eligible for but not receiving sodium glucose cotransporter-2 inhibitors. Optimal implementation of quadruple GDMT could potentially prevent 1 188 277 (95% CI, 767 933-1 914 561) deaths over 12 months. A large proportion of deaths averted were projected in Southeast Asia, Eastern Mediterranean and Africa, and the Western Pacific regions.
Improvement in use of GDMT could result in substantial mortality benefits on a global scale. Significant heterogeneity also exists across regions, which warrants additional study with interventions tailored to country-level differences for optimization of GDMT worldwide.
在全球范围内，指南指导的药物治疗（GDMT）的应用仍然不足，全球在治疗可及性方面存在显著差异。四重疗法对射血分数降低的心力衰竭（HFrEF）患者的潜在全球益处尚未得到评估。
评估全球范围内HFrEF患者最佳使用GDMT预计在人群水平上带来的益处。
设计、背景和参与者：HFrEF患病率、GDMT禁忌症、治疗率以及12个月时全因死亡率的治疗所需人数估计值来自先前发表的资料。计算了全球范围内HFrEF患者通过最佳实施四重疗法可能挽救的生命数量，并进行了敏感性分析以考虑现有数据中的不确定性。
全因死亡率。
全球估计有2889万HFrEF患者，其中有8235063人（95%CI，6296020 - 10762972）有资格使用但未接受β受体阻滞剂治疗，20387000人（95%CI，15867004 - 26184996）有资格使用但未接受血管紧张素受体脑啡肽酶抑制剂治疗，12223700人（95%CI，9376895 - 15924973）有资格使用但未接受盐皮质激素受体拮抗剂治疗，21229170人（95%CI，16537400 - 27242688）有资格使用但未接受钠-葡萄糖协同转运蛋白2抑制剂治疗。最佳实施四重GDMT在12个月内可能预防1188277例（95%CI，767933 - 1914561）死亡。预计在东南亚、东地中海和非洲以及西太平洋地区可避免的死亡比例较大。
改善GDMT的使用可在全球范围内带来显著的死亡率益处。各地区之间也存在显著的异质性，这需要针对国家层面的差异进行额外研究，并采取相应干预措施，以在全球范围内优化GDMT的使用。
