Titration of Medical Therapy for Heart Failure With Reduced Ejection Fraction

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

卷:73

Article

Greene, Stephen J.^1,2  Fonarow, Gregg C.³  DeVore, Adam D.^1,2  Sharma, Puza P.⁴  Vaduganathan, Muthiah^5,6  Albert, Nancy M.^7,8  Duffy, Carol, I⁴  Hill, Larry¹  McCague, Kevin⁴  Patterson, J. Herbert⁹  Spertus, John A.^10,11  Thomas, Laine¹  Williams, Fredonia B.¹²  Hernandez, Adrian F.^1,10,11  Butler, Javed¹³ 

[1] Duke Clin Res Inst, Durham, NC USA

[2] Duke Univ, Sch Med, Div Cardiol, Durham, NC USA

[3] Univ Calif Los Angeles, Ahmanson UCLA Cardiomyopathy Ctr, Los Angeles, CA USA

[4] Novartis Pharmaceut, E Hanover, NJ USA

[5] Brigham & Womens Hosp, Heart & Vasc Ctr, 75 Francis St, Boston, MA 02115 USA

[6] Harvard Med Sch, Boston, MA 02115 USA

[7] Cleveland Clin, Nursing Inst, Cleveland, OH 44106 USA

[8] Cleveland Clin, Kaufman Ctr Heart Failure, Cleveland, OH 44106 USA

[9] Univ N Carolina, Eshelman Sch Pharm, Chapel Hill, NC 27515 USA

[10] St Lukes Mid Amer Heart Inst, Kansas City, MO USA

[11] Univ Missouri, Kansas City, MO 64110 USA

[12] Mended Hearts, Huntsville, AL USA

[13] Univ Mississippi, Dept Med, Med Ctr, L650,2500 N State St, Jackson, MS 39216 USA

关键词: dose;    heart failure;    medication;    reduced ejection fraction;    registry;   

DOI  :  10.1016/j.jacc.2019.02.015

来源: Elsevier

【 摘 要 】

BACKGROUND Guidelines recommend that patients with heart failure with reduced ejection fraction (HFrEF) have medical therapy titrated to target doses derived from clinical trials, as tolerated. The degree to which titration occurs in contemporary U.S. practice is unknown. OBJECTIVES This study sought to characterize longitudinal titration of HFrEF medical therapy in clinical practice and to identify associated factors and reasons for medication changes. METHODS Among 2,588 U.S. outpatients with chronic HFrEF in the CHAMP-HF (Change the Management of Patients with Heart Failure) registry with complete medication data and no contraindications to medical therapy, use and dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker, and mineralocorticoid receptor antagonist (MRA) were examined at baseline and at 12-month follow-up. RESULTS At baseline, 658 (25%), 525 (20%), 287 (11%), and 45 (2%) patients were receiving target doses of MRA, beta-blocker, ACEI/ARB, and ARNI therapy, respectively. At 12 months, proportions of patients with medication initiation or dose increase were 6% for MRA, 10% for beta-blocker, 7% for ACEI/ARB, and 10% for ARNI; corresponding proportions with discontinuation or dose decrease were 4%, 7%, 11%, and 3%, respectively. Over 12 months, <1% of patients were simultaneously treated with target doses of ACEI/ARB/ARNI, beta-blocker, and MRA. In multivariate analysis, across the classes of medications, multiple patient characteristics were associated with a higher likelihood of initiation or dose increase (e.g., previous HF hospitalization, higher blood pressure, lower ejection fraction) and discontinuation or dose decrease (e.g., previous HF hospitalization, impaired quality of life, more severe functional class). Medical reasons were the most common reasons for discontinuations and dose decreases of each therapy, but the relative contributions from patient preference, health team, and systems-based reasons varied by medication. CONCLUSIONS In this contemporary U. S. registry, most eligible HFrEF patients did not receive target doses of medical therapy at any point during follow-up, and few patients had doses increased over time. Although most patients had no alterations in medical therapy, multiple clinical factors were independently associated with medication changes. Further quality improvement efforts are urgently needed to improve guideline-directed medication titration for HFrEF. (c) 2019 by the American College of Cardiology Foundation.

【 授权许可】

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