Digoxin Discontinuation and Outcomes in Patients With Heart Failure With Reduced Ejection Fraction.
Digoxin Discontinuation and Outcomes in Patients With Heart Failure With Reduced Ejection Fraction.
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DOI：
10.1016/j.jacc.2019.05.064
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发表时间：
2019-08-06
影响因子：
24
通讯作者：
Ahmed, Ali
中科院分区：
文献类型：
--
作者：
Malik, Awais;Masson, Ravi;Singh, Steven;Wu, Wen-Chih;Packer, Milton;Pitt, Bertram;Waagstein, Finn;Morgan, Charity J.;Allman, Richard M.;Fonarow, Gregg C.;Ahmed, Ali
地高辛停药对接受血管紧张素转换酶（ACE）抑制剂治疗的慢性心力衰竭伴射血分数降低（HFrEF）非卧床患者结局的有害影响已有充分记录。确定地高辛停药与接受更现代指南指导的药物治疗（GDMT）（包括β受体阻滞剂和盐皮质激素受体拮抗剂（MRA））的HFrEF住院患者结局之间的关系。在Medicare相关OPTIMIZE-HF的11，900例HFrEF（EF ≤45%）住院患者中，3，499例患者在入院前接受地高辛治疗，721例患者停用地高辛。使用地高辛停药的倾向评分，对3，499例患者中的每一位进行估计，我们收集了698对患者的匹配队列，在50个基线特征上平衡（平均年龄，76岁;平均EF，28%; 41%女性; 13%非洲裔美国人; 65% β受体阻滞剂）。出院后4年，地高辛停药与HF再入院风险显著升高相关（HR，1.21; 95%CI，1.05-1.39; p=0.007），全因再入院（HR，1.16; 95% CI，1.04-1.31; p=0.010），以及HF再入院或全因死亡率的联合终点（HR，1.20; 95% CI，1.07-1.34; p=0.002），但非全因死亡率（HR，1.09; 95% CI，0.97-1.24; p=0.163）。在出院后6个月和1年，停用地高辛与所有4种结局的风险显著升高相关。在30天时，地高辛停药与全因死亡率的高风险相关（HR，1.80; 95% CI，1.26-2.57; p=0.001）和联合终点（HR，1.36; 95% CI，1.07-1.71; p=0.007），但不包括HF再入院（HR，1.19; 95% CI，0.90-1.59; p=0.226）或全因再入院（HR，1.03; 95% CI，0.84-1.26; p=0.778）。在接受更现代GDMT的HFrEF住院老年患者中，停用长期地高辛治疗与不良结局相关。地高辛停药对未接受现代指南指导药物治疗（GDMT）的慢性心力衰竭伴射血分数降低（HFrEF）非卧床患者结局的有害影响是众所周知的。在目前的倾向评分匹配研究中，我们证明了在接受GDMT的HFrEF住院患者中，停止长期地高辛治疗与不良结局相关。这些发现突出了接受当代GDMT（包括β受体阻滞剂和盐皮质激素受体拮抗剂）的HFrEF住院患者中地高辛停药相关的不良结局。
The deleterious effects of discontinuation of digoxin on outcomes in ambulatory patients with chronic heart failure with reduced ejection fraction (HFrEF) receiving angiotensin-converting enzyme (ACE) inhibitors are well-documented. To determine the relationship between digoxin discontinuation and outcomes in hospitalized patients with HFrEF receiving more contemporary guideline-directed medical therapies (GDMT) including beta-blockers and mineralocorticoid receptor antagonists (MRAs). Of the 11,900 hospitalized patients with HFrEF (EF ≤45%) in Medicare-linked OPTIMIZE-HF, 3,499 received pre-admission digoxin, which was discontinued in 721 patients. Using propensity scores for digoxin discontinuation, estimated for each of the 3,499 patients, we assembled a matched cohort of 698 pairs of patients, balanced on 50 baseline characteristics (mean age, 76 years; mean EF, 28%; 41% women; 13% African American; 65% on beta-blockers). Four-year post-discharge, digoxin discontinuation was associated with significantly higher risks of HF readmission (HR, 1.21; 95% CI, 1.05–1.39; p=0.007), all-cause readmission (HR, 1.16; 95% CI, 1.04–1.31; p=0.010), and the combined endpoint of HF readmission or all-cause mortality (HR, 1.20; 95% CI, 1.07–1.34; p=0.002), but not all-cause mortality (HR, 1.09; 95% CI, 0.97–1.24; p=0.163). Discontinuation of digoxin was associated with a significantly higher risk of all 4 outcomes at 6-month and 1-year post-discharge. At 30 days, digoxin discontinuation was associated with higher risks of all-cause mortality (HR, 1.80; 95% CI, 1.26–2.57; p=0.001) and the combined endpoint (HR, 1.36; 95% CI, 1.07–1.71; p=0.007) but not of HF readmission (HR, 1.19; 95% CI, 0.90–1.59; p=0.226) or all-cause readmission (HR, 1.03; 95% CI, 0.84–1.26; p=0.778). Among hospitalized older patients with HFrEF on more contemporary GDMT, discontinuation of chronic digoxin therapy was associated with poor outcomes. The deleterious effects of discontinuation of digoxin on outcomes in ambulatory patients with chronic heart failure with reduced ejection fraction (HFrEF) not receiving more contemporary guideline-directed medical therapy (GDMT) are well-known. In the current propensity score-matched study, we demonstrate that discontinuation of chronic digoxin therapy is associated with poor outcomes in hospitalized patients with HFrEF receiving GDMT. These findings highlight the negative outcomes associated with digoxin discontinuation in hospitalized patients with HFrEF receiving contemporary GDMT including beta-blockers and mineralocorticoid receptor antagonists.
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影响因子：
5.9
作者：
Ahmed, Ali;Fonarow, Gregg C.;Zhang, Yan;Sanders, Paul W.;Allman, Richard M.;Arnett, Donna K.;Feller, Margaret A.;Love, Thomas E.;Aban, Inmaculada B.;Levesque, Raynald;Ekundayo, O. James;Dell'Italia, Louis J.;Bakris, George L.;Rich, Michael W.
通讯作者：
Rich, Michael W.
影响因子：
13
作者：
Patel, Nish;Ju, Christine;Fonarow, Gregg C.
通讯作者：
Fonarow, Gregg C.
影响因子：
18.2
作者：
Gheorghiade, Mihai;Patel, Kanan;Ahmed, Ali
通讯作者：
Ahmed, Ali
影响因子：
5.9
作者：
Ahmed, Ali;Bourge, Robert C.;Allman, Richard M.
通讯作者：
Allman, Richard M.
影响因子：
5.9
作者：
COVIT, AB;SCHAER, GL;CODY, RJ
通讯作者：
CODY, RJ