Srivastava Pratyaksh K, Klomhaus Alexandra M, Greene Stephen J, Heidenreich Paul, Lewsey Sabra C, Yancy Clyde W, Fonarow Gregg C
Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, California.
Department of Medicine, Statistics Core, UCLA, Los Angeles, California.
JAMA Cardiol. 2025 Mar 1;10(3):276-283. doi: 10.1001/jamacardio.2024.3815.
Angiotensin receptor-neprilysin inhibition (ARNI) improves mortality among patients with heart failure with reduced ejection fraction (HFrEF), ie, those with an EF of 40% or less.
To describe national longitudinal trends in ARNI prescribing patterns among hospitalized patients with HFrEF.
DESIGN, SETTING, AND PARTICIPANTS: Using data from the Get With The Guidelines-Heart Failure (GWTG-HF) registry, hospitalized patients with HFrEF at 614 participating hospitals were identified. Rates of ARNI, angiotensin converting enzyme inhibitor (ACEI), and angiotensin II receptor blocker (ARB) prescription at discharge were evaluated across 3 time periods. Adjusted logistic regression and piecewise logistic regression were used to evaluate the impact of publication dates on ARNI prescription rates.
ARNI prescribing patterns in hospitalized patients with HFrEF.
Rates of ARNI, ACEI, and ARB prescription at discharge were evaluated across 3 time periods as follows: (1) period 1 included the US Food and Drug Administration (FDA) approval of sacubitril-valsartan to the day before the PIONEER-HF (Comparison of Sacubitril-Valsartan vs Enalapril on Effect on N-Terminal Pro-Brain Natriuretic Peptide in Patients Stabilized From an Acute Heart Failure Episode) trial publication (July 7, 2015-November 10, 2018); (2) period 2 included the day of the PIONEER-HF trial publication to the day before publication of the 2021 Update to the 2017 Consensus for Optimization of Heart Failure Treatment (November 11, 2018-January 10, 2021); and (3) period 3 included the day of the 2021 update publication to the last available data at the time of analysis (January 11, 2021-December 31, 2022).
A total of 114 333 hospitalized patients (mean [IQR] age, 67.0 [57.0-78.0] years; 74 765 male [65.4%]) were included in this study. Rates of ARNI prescribed at discharge increased from 1.1% (27 of 2451) during July 7, 2015, to September 30, 2015, to 55.4% (1957 of 3536) during October 1, 2022, to December 31, 2022. ACEI or ARB prescription at discharge fell from 88.3% (2612 of 2957) to 45.9% (2033 of 4434) over the same period, whereas ACEI, ARB, or ARNI prescription increased from 71.1% (2639 of 3713) to 84.7% (3990 of 4711). In adjusted logistic regression models, compared with period 1, patients discharged during period 2 and period 3 were found to have a 3.81-fold (95% CI, 3.65-3.98) and 9.15-fold (95% CI, 8.79-9.52) increased odds of ARNI prescription at discharge, and a 0.46 (95% CI, 0.45-0.48) and 0.25 (95% CI, 0.24-0.26) decreased odds of ACEI or ARB prescription at discharge.
Results of this cross-sectional study reveal that in the 7 years after FDA drug approval of sacubitril-valsartan, rates of ARNI or ACEI, ARB, or ARNI prescription at discharge increased, and rates of ACEI or ARB prescription decreased. Overall prescription of ARNI at discharge was 55.4% in eligible patients at the end of the study, suggesting remaining opportunity for continued improvement in ARNI prescription.
血管紧张素受体脑啡肽酶抑制剂（ARNI）可降低射血分数降低的心力衰竭（HFrEF）患者（即射血分数为40%或更低的患者）的死亡率。
描述住院HFrEF患者中ARNI处方模式的全国纵向趋势。
设计、设置和参与者：利用“遵循心力衰竭治疗指南”（GWTG-HF）注册研究的数据，确定了614家参与医院的住院HFrEF患者。评估了3个时间段出院时ARNI、血管紧张素转换酶抑制剂（ACEI）和血管紧张素II受体阻滞剂（ARB）的处方率。采用调整后的逻辑回归和分段逻辑回归来评估发表日期对ARNI处方率的影响。
住院HFrEF患者的ARNI处方模式。
在3个时间段评估出院时ARNI、ACEI和ARB的处方率如下：（1）第1阶段包括美国食品药品监督管理局（FDA）批准沙库巴曲缬沙坦至“先锋-HF”（沙库巴曲缬沙坦与依那普利对急性心力衰竭发作稳定患者N末端脑钠肽前体影响的比较）试验发表前一天（2015年7月7日至2018年11月10日）；（2）第2阶段包括“先锋-HF”试验发表当天至《2017年心力衰竭治疗优化共识2021年更新》发表前一天（2018年11月11日至2021年1月10日）；（3）第3阶段包括2021年更新发表当天至分析时的最后可用数据（2021年1月11日至2022年12月31日）。
本研究共纳入114333例住院患者（平均[四分位间距]年龄为67.0[57.0 - 78.0]岁；74765例男性[65.4%]）。出院时ARNI的处方率从2015年7月7日至2015年9月30日的1.1%（2451例中的27例）增至2022年10月1日至2022年12月31日的55.4%（3536例中的1957例）。同期出院时ACEI或ARB的处方率从88.3%（2957例中的2612例）降至45.9%（4434例中的2033例），而ACEI、ARB或ARNI的处方率从71.1%（3713例中的2639例）增至84.7%（4711例中的3990例）。在调整后的逻辑回归模型中，与第1阶段相比，第2阶段和第3阶段出院的患者出院时ARNI处方的优势比分别增加3.81倍（95%置信区间，3.65 - 3.98）和9.15倍（95%置信区间，8.79 - 9.52），ACEI或ARB处方的优势比分别降低0.46（95%置信区间，0.45 - 0.48）和0.25（95%置信区间，0.24 - 0.26）。
这项横断面研究的结果显示，在FDA批准沙库巴曲缬沙坦后的7年里，出院时ARNI或ACEI、ARB或ARNI的处方率增加，而ACEI或ARB的处方率降低。在研究结束时，符合条件的患者出院时ARNI的总体处方率为55.4%，这表明ARNI处方仍有持续改善的空间。
