Use of Mineralocorticoid Receptor Antagonists in Patients With Heart Failure and Comorbid Diabetes Mellitus or Chronic Kidney Disease.
Use of Mineralocorticoid Receptor Antagonists in Patients With Heart Failure and Comorbid Diabetes Mellitus or Chronic Kidney Disease.
复制标题
在心力衰竭和合并症糖尿病或慢性肾脏疾病的患者中使用矿物皮质受体拮抗剂。
DOI：
10.1161/jaha.117.006540
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发表时间：
2017-12-23
影响因子：
5.4
通讯作者：
Hernandez AF
中科院分区：
文献类型：
--
作者：
Cooper LB;Lippmann SJ;Greiner MA;Sharma A;Kelly JP;Fonarow GC;Yancy CW;Heidenreich PA;Hernandez AF
高钾血症和急性肾功能不全的感知风险可能会限制心力衰竭患者（尤其是糖尿病或慢性肾病患者）使用盐皮质激素受体拮抗剂（MRA）治疗。使用与医疗保险索赔相关的临床登记数据，我们分析了2005年至2013年期间因心力衰竭住院的糖尿病或慢性肾脏病史患者。我们根据出院时MRA的使用情况对患者进行分层。我们使用逆概率加权比例风险模型来评估MRA治疗与30天、1年和3年死亡率、全因再入院以及因心力衰竭、高钾血症和急性肾功能不全再入院之间的相关性。我们对射血分数降低、临界和保留的3年结局的不同影响进行了相互作用分析。在16848例患者中，12.3%的患者在出院时接受了MRA治疗。较高的血清肌酐与较低的MRA使用几率相关（比值比，0.66; 95%置信区间，0.61-0.71）;血清钾与此无关（比值比，1.00; 95%置信区间，0.90-1.11）。两组之间的死亡率无差异。MRA治疗与高钾血症和急性肾功能不全再入院的风险较高以及长期全因再入院的风险较低相关。接受MRA治疗的射血分数处于临界或保留的患者因高钾血症（P=0.02）和急性肾功能不全（P<0.001）而再次入院的风险更大;射血分数降低的患者则无此风险。在心力衰竭和糖尿病或慢性肾脏疾病患者中，尽管高钾血症和急性肾功能不全的风险较高，但MRA的使用与全因再入院的风险较低相关。
Perceived risks of hyperkalemia and acute renal insufficiency may limit use of mineralocorticoid receptor antagonist (MRA) therapy in patients with heart failure, especially those with diabetes mellitus or chronic kidney disease. Using clinical registry data linked to Medicare claims, we analyzed patients hospitalized with heart failure between 2005 and 2013 with a history of diabetes mellitus or chronic kidney disease. We stratified patients by MRA use at discharge. We used inverse probability–weighted proportional hazards models to assess associations between MRA therapy and 30‐day, 1‐year, and 3‐year mortality, all‐cause readmission, and readmission for heart failure, hyperkalemia, and acute renal insufficiency. We performed interaction analyses for differential effects on 3‐year outcomes for reduced, borderline, and preserved ejection fraction. Of 16 848 patients, 12.3% received MRA therapy at discharge. Higher serum creatinine was associated with lower odds of MRA use (odds ratio, 0.66; 95% confidence interval, 0.61–0.71); serum potassium was not (odds ratio, 1.00; 95% confidence interval, 0.90–1.11). There was no mortality difference between groups. MRA therapy was associated with greater risks of readmission for hyperkalemia and acute renal insufficiency and lower risks of long‐term all‐cause readmission. Patients on MRA therapy with borderline or preserved ejection fraction had greater risks of readmission for hyperkalemia (P=0.02) and acute renal insufficiency (P<0.001); patients with reduced ejection fraction did not. Among patients with heart failure and diabetes mellitus or chronic kidney disease, MRA use was associated with lower risk of all‐cause readmission despite greater risk of hyperkalemia and acute renal insufficiency.