Huang Chi-Cheng, Tzeng Bing-Hsiean, Tsai Hao-Yuan, Lee Chien-Lin, Huang Shan-Hui, Yeh Yen-Ting, Hsu Jung-Cheng, Chien Chung-Liang, Wu Yen-Wen
Graduate Institute of Anatomy and Cell Biology, College of Medicine, National Taiwan University, Taipei.
Division of Cardiology, Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City.
Acta Cardiol Sin. 2025 Jul;41(4):510-520. doi: 10.6515/ACS.202507_41(4).20250324A.
Current evidence supports the early initiation of all guideline-directed medical therapy (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF), but clinical inertia persists in real-world practice.
Clinical data of 343 HFrEF patients hospitalized from January 2018 to December 2019 were collected, and they were followed for at least 3 years. We analyzed the benefits of optimizing GDMT at hospital discharge, the reasons for underprescription of GDMT, and factors associated with different outcomes after multivariate adjustments.
Starting at least 3 pillars of GDMT at hospital discharge significantly reduced the risks of all-cause mortality, cardiovascular (CV) death, and heart failure hospitalization (hazard ratio = 0.22, 0.21, 0.28, respectively; all p < 0.001). Renal impairment was the major factor associated with the non-optimization of GDMT, and 78.4% of patients receiving fewer than 3 pillars of GDMT had a baseline chronic kidney disease stage 3-5. However, the prescription of GDMT was not associated with any observable risk of adverse renal outcomes.
This study demonstrated the CV benefits and safety regarding renal outcomes with the early initiation of GDMT in HFrEF patients. Efforts should be made to address the disparity between evidence-based medicine and daily practice.
现有证据支持对射血分数降低的心力衰竭（HFrEF）患者尽早启动所有指南指导的药物治疗（GDMT），但在实际临床实践中，临床惰性依然存在。
收集了2018年1月至2019年12月期间住院的343例HFrEF患者的临床资料，并对他们进行了至少3年的随访。我们分析了出院时优化GDMT的益处、GDMT处方不足的原因以及多变量调整后与不同结局相关的因素。
出院时启动至少3项GDMT支柱疗法可显著降低全因死亡率、心血管（CV）死亡和心力衰竭住院的风险（风险比分别为0.22、0.21、0.28；均p<0.001）。肾功能损害是与GDMT未优化相关的主要因素，接受少于3项GDMT支柱疗法的患者中78.4%基线慢性肾脏病为3-5期。然而，GDMT的处方与任何可观察到的不良肾脏结局风险无关。
本研究证明了HFrEF患者早期启动GDMT在心血管方面的益处以及肾脏结局的安全性。应努力解决循证医学与日常实践之间的差距。
