Sacubitril/valsartan in heart failure patients:An analysis on the prescription and treatment patterns
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摘要: 目的:探讨血管紧张素受体脑啡肽酶抑制剂(ARNI)沙库巴曲缬沙坦在射血分数降低的心力衰竭(HFrEF)患者中的用药策略。方法:对199例使用ARNI的HFrEF患者进行6个月随访,观察ARNI用药剂量变化,比较治疗前后患者的收缩压、心率、实验室检查水平、超声心动图参数以及β-受体阻滞剂、螺内酯、袢利尿剂的用药剂量,对影响ARNI剂量变化的因素进行分析。结果:8例(4.0%)患者滴定至靶剂量,103例(52.0%)患者维持在低于靶剂量的水平没有变化。治疗6个月后,患者的收缩压、心率、N末端B型利钠肽原(NT-proBNP)较治疗前均明显下降(P＜0.01),左室射血分数(LVEF)较治疗前明显提升(P＜0.01)。6个月后,β-受体阻滞剂日剂量≥95 mg的比例较前上升6%(以琥珀酸美托洛尔为参考);袢利尿剂整体使用剂量较基线明显减少,日剂量40 mg的比例由44.7%下降为37.7%(以呋塞米为参考);螺内酯日剂量为20 mg的比例较前变化不大,由87.9%下降为85.4%。多因素Logistic回归分析显示,再住院(OR=2.90,95%CI:1.22~8.52,P＜0.05)是ARNI剂量增加的相关因素;收缩压＜100 mmHg(OR=4.12,95%CI:1.54~11.02,P＜0.01)、LVEF＜30%(OR=0.28,95%CI:0.14~0.56,P＜0.01)是ARNI剂量减少或撤药的相关因素。结论:目前ARNI治疗策略由小剂量起始,大部分患者维持在低于靶剂量的水平没有变化,极少数能够滴定至靶剂量。滴定由再住院实现,缺乏患者长期随访和管理是阻碍指南导向药物治疗滴定的关键因素,需加强以达到最佳获益。Abstract: Objective:To figure out the prescription and analyse real-world treatment patterns of Sacubitril/valsartan(ARNI) in heart failure with reduced ejection fraction(HFrEF) patients.Method:After a 6-months follow-up of 199 consecutive patients diagnosed with HFrEF meanwhile using the ARNI,we compared the systolic blood pressure,heart rate,laboratory data,echocardiographic images,and β-receptor blockers,spirolactone,loop diuretics doses changes before and after the prescription.Multivariate logistic regression analysis was used to evaluate the risk factors of dose changes.Result:Of the 199 patients,8(4.0%) were titration to target dose,while 103(52%) had no ARNI dose change during the 6 months.After treatment,the systolic blood pressure,NT-proBNP were decreased significantly(P＜0.01),left ventricular ejection fraction(LVEF) was significantly improved(P＜0.01).After treatment,the daily doses of β receptor blockers which ≥95 mg increased by 6%(metoprolol succinate equivalent),daily loop diuretics dosage at 40 mg were decreased from 44.7% to 37.7%,spirolactone daily dosage at 20 mg changed little from 87.9% to 85.4%.Multivariate Logistic regression analysis indicated that rehospitalization(OR=2.90,95%CI:1.22—8.52,P＜0.05) was an independent predictor of ARNI up-titration,systolic blood pressure ＜100 mmHg(OR=4.12,95%CI:1.54—11.02,P＜0.01),LVEF＜30%(OR=0.28,95%CI:0.14—0.56,P＜0.01) were predictors of ARNI down-titration or withdrawal.Conclusion:Most patients initially prescribed ARNI at a lowest dose,the major part stayed still at a small dose and few titrated at the target dose.Hospitalization is a potential time for ARNI titration;therefore a regular outpatient follow-up makes sense for guideline-directed medication therapy(GDMT) and needs to be reinforced to achieve optimal benefit.
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Key words:
- sacubitril/valsartan /
- heart failure /
- up-titration /
- GDMT
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