衰弱会干扰射血分数降低的心力衰竭患者的指南指导的医学治疗。
Frailty interferes with the guideline-directed medical therapy in heart failure patients with reduced ejection fraction.
机构信息
Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Oko-cho, Nankoku-shi, Kochi, 783-8505, Japan.
Department of Cardiology, Chikamori Hospital, Kochi, Japan.
出版信息
ESC Heart Fail. 2023 Feb;10(1):223-233. doi: 10.1002/ehf2.14163. Epub 2022 Oct 3.
AIMS
Guideline-directed medical therapy (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF) is recommended in clinical guidelines, but elderly patients have not fully received GDMT in the clinical situation. The aim of this study was to determine the clinical characteristics of patients who have not received GDMT and the association between implementation of GDMT at discharge and physical frailty in patients with HFrEF who were hospitalized for acute decompensated heart failure (ADHF).
METHODS AND RESULTS
This study was a cross-sectional study with a retrospective analysis of the Kochi YOSACOI study, a prospective multicentre observational study that enrolled 1061 patients hospitalized for ADHF from May 2017 to December 2019 in Japan. Of 339 patients (32.0%) with HFrEF, 268 patients who were assessed for physical frailty by the Japanese version of the Cardiovascular Health Study criteria were divided into two groups: those with GDMT (135 patients, 50.4%) and those without GDMT (133 patients, 49.6%). GDMT was defined as the prescription of a combination of renin-angiotensin system (RAS) inhibitors (angiotensin-converting inhibitors or angiotensin receptor blockers) and beta-blockers. The median age of patients with HFrEF was 76 years (interquartile range, 67-83 years). Patients without GDMT were older than patients with GDMT (73 years vs. 78 years, P < 0.001). Patients without GDMT tended to have more prior HF admission than did patients with GDMT (P = 0.004), and patients without GDMT had lower levels of estimated glomerular filtration rate (P < 0.001) than those in patients with GDMT. Physical frailty was observed in 54.1% of the patients without GDMT and in 38.5% of the patients with GDMT (P = 0.014). Patients without GDMT had a higher rate of cognitive impairment than that in patients with GDMT (P = 0.009). RAS inhibitors only, beta-blockers only, and both RAS inhibitors and beta-blockers were less frequently prescribed in patients with physical frailty than in patients with physical non-frailty (52.0% vs. 86.7%, P < 0.05; 70.1% vs. 100.0%, P < 0.05; 42.5% vs. 86.7%, P < 0.01, respectively). In logistic regression analysis, compared with physical non-frailty, physical frailty was significantly associated with no implementation of GDMT (odds ratio: 6.900, 95% confidence interval: 1.420-33.600; P = 0.017), independent of older age and severe renal dysfunction.
CONCLUSIONS
The results of this study suggest that physical frailty is one of the factors that may withhold GDMT in patients with HFrEF.
目的
临床指南推荐对射血分数降低的心力衰竭（HFrEF）患者进行指南指导的医学治疗（GDMT），但在临床情况下，老年患者并未充分接受 GDMT。本研究旨在确定未接受 GDMT 的患者的临床特征，以及在因急性失代偿性心力衰竭（ADHF）住院的 HFrEF 患者中，出院时实施 GDMT 与身体虚弱之间的关联。
方法和结果
本研究是一项回顾性分析的横断面研究，使用了日本 2017 年 5 月至 2019 年 12 月期间从多中心前瞻性观察性研究 Kochi YOSACOI 研究中招募的 1061 例 ADHF 住院患者的资料。在 339 例 HFrEF 患者（32.0%）中，根据心血管健康研究标准的日版评估身体虚弱的 268 例患者分为两组：接受 GDMT（135 例，50.4%）和未接受 GDMT（133 例，49.6%）。GDMT 定义为联合使用肾素-血管紧张素系统（RAS）抑制剂（血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂）和β受体阻滞剂。HFrEF 患者的中位年龄为 76 岁（四分位距，67-83 岁）。未接受 GDMT 的患者比接受 GDMT 的患者年龄更大（73 岁比 78 岁，P<0.001）。与接受 GDMT 的患者相比，未接受 GDMT 的患者更倾向于有更多的心力衰竭入院史（P=0.004），且未接受 GDMT 的患者的估算肾小球滤过率水平更低（P<0.001）。未接受 GDMT 的患者中有 54.1%表现出身体虚弱，而接受 GDMT 的患者中有 38.5%表现出身体虚弱（P=0.014）。与接受 GDMT 的患者相比，未接受 GDMT 的患者认知障碍的发生率更高（P=0.009）。与身体非虚弱患者相比，身体虚弱患者接受 RAS 抑制剂单药治疗、β受体阻滞剂单药治疗和 RAS 抑制剂与β受体阻滞剂联合治疗的比例更低（52.0%比 86.7%，P<0.05；70.1%比 100.0%，P<0.05；42.5%比 86.7%，P<0.01，分别）。在 logistic 回归分析中，与身体非虚弱相比，身体虚弱与未实施 GDMT 显著相关（比值比：6.900，95%置信区间：1.420-33.600；P=0.017），独立于年龄较大和严重肾功能障碍。
结论
本研究结果表明，身体虚弱可能是导致 HFrEF 患者未实施 GDMT 的因素之一。
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