Association of Renin-Angiotensin Inhibitor Treatment With Mortality and Heart Failure Readmission in Patients With Transcatheter Aortic Valve Replacement
Association of Renin-Angiotensin Inhibitor Treatment With Mortality and Heart Failure Readmission in Patients With Transcatheter Aortic Valve Replacement
复制标题
DOI：
10.1001/jama.2018.18077
复制
发表时间：
2018-12-04
影响因子：
120.7
通讯作者：
Vemulapalli, Sreekanth
中科院分区：
文献类型：
--
作者：
Inohara, Taku;Manandhar, Pratik;Vemulapalli, Sreekanth
重要性：缺乏经导管主动脉瓣置换术（TAVR）后处方的肾素-血管紧张素系统（RAS）抑制剂的作用数据。RAS抑制剂治疗可逆转左心室重构并改善功能。目的研究RAS抑制剂处方与TAVR术后结局的相关性。设计，环境，和参与者在美国进行的TAVR手术的回顾性队列研究（使用胸外科医师协会/美国心脏病学会经导管瓣膜治疗登记研究）2014年7月至2016年1月期间，与Medicare数据相关（随访的最终日期：2017年3月31日）。为了解释人口统计学、超声心动图检查结果和住院并发症的差异，进行了1：1倾向匹配。EXPOSURES TAVR后RAS抑制剂的初始出院处方。主要结局和指标主要结局是出院后1年时的全因死亡和因心力衰竭再次入院，这两项分别考虑。次要结局是通过堪萨斯城心肌病问卷（KCCQ）评估的健康状况;评分范围：0-100。评分越高，表明症状负担越轻，生活质量越好; 1年时的小效应量定义为5分）。8468例患者（39.7%）在出院时接受了RAS抑制剂处方。经过倾向匹配后，纳入了15896例患者（平均[SD]年龄，82.4 [6.8]岁; 48.1%为女性;平均[SD]左心室射血分数[LVEF]，51.9% [11.5%]）。有RAS抑制剂处方的患者与无处方的患者相比，1年死亡率较低（分别为12.5%和14.9%;绝对风险差异[ARD]，-2.4% [95% CI，-3.5%至-1.4%];风险比[HR]，0.82 [95% CI，0.76 - 0.90]）和1年时较低的心力衰竭再入院率（12.0% vs 13.8%; ARD，-1.8% [95% CI，-2.8%至-0.7%]：HR，0.86 [95% CI，0.79至0.95]）。当按LVEF分层时，在LVEF保留的患者中，有RAS抑制剂处方与无处方相比，1年死亡率较低（分别为11.1%和13.9%; ARD，-2.81% [95% CI，-3.95%至-1.67%]; HR.0.78 [95%CI，0.71至0.86]），但在LVEF降低的患者中并非如此（18.8% vs 19.5%; ARD，-0.68% [95% CI，-3.52%至2.20%]; HR，0.95 [95% CI，0.81至1.12]）= 0.04（相互作用）。在15896例匹配的患者中，4837例（30.4%）被纳入KCCQ评分分析，1年时接受RAS抑制剂处方的患者的改善程度高于未接受RAS抑制剂处方的患者（中位数分别为33.3 [四分位距，14.2至51.0] vs 31.3 [四分位距，13.5至51.1];改善差异，2.10 [95% CI，0.10 - 4.06]; P < .001），但效应量无临床意义。结论和相关性在接受TAVR的患者中，出院时接受RAS抑制剂处方与未接受处方相比，死亡风险显著降低和心力衰竭再入院然而，由于潜在的选择偏倚，这一发现需要在随机试验中进一步研究。
IMPORTANCE Data are lacking on the effect of a renin-angiotensin system (RAS) inhibitor prescribed after transcatheter aortic valve replacement (TAVR). Treatment with a RAS inhibitor may reverse left ventricular remodeling and improve function.OBJECTIVE To investigate the association of prescription of a RAS inhibitor and outcomes after TAVR.DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of TAVR procedures performed in the United States (using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry) between July 2014 and January 2016 that were linked to Medicare daims data (final date of follow-up: March 31, 2017). To account for differences in demographics, echocardiographic findings, and in-hospital complications, 1:1 propensity matching was performed.EXPOSURES Initial hospital discharge prescription of a RAS inhibitor after TAVR.MAIN OUTCOMES AND MEASURES Primary outcomes were all-cause death and readmission due to heart failure at 1 year after discharge, which were considered separately. The secondary outcome was health status assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ; score range: 0-100. with a higher score indicating less symptom burden and better quality of life; a small effect size was defined as 5 points) at 1 year.RESULTS Among 21312 patients who underwent TAVR at 417 US sites. 8468 patients (39.7%) were prescribed a RAS inhibitor at hospital discharge. After propensity matching, 15 896 patients were included (mean [SD] age, 82.4 [6.8] years; 48.1% were women; mean [SD] left ventricular ejection fraction [LVEF], 51.9% [11.5%]). Patients with a prescription for a RAS inhibitor vs those with no prescription had lower mortality rates at 1 year (12.5% vs 14.9%, respectively; absolute risk difference [ARD], -2.4% [95% CI, -3.5% to -1.4%]; hazard ratio [HR], 0.82 [95% CI, 0.76 to 0.90]) and lower heart failure readmission rates at 1 year (12.0% vs 13.8%; ARD, -1.8% [95% CI, -2.8% to -0.7%]: HR, 0.86 [95% CI, 0.79 to 0.95]). When stratified by LVEF, having a prescription for a RAS inhibitor vs no prescription was associated with lower 1-year mortality among patients with preserved LVEF (11.1% vs 13.9%, respectively; ARD, -2.81% [95% CI, -3.95% to -1.67%]; HR. 0.78 [95% CI, 0.71to 0.86]), but not among those with reduced LVEF (18.8% vs 19.5%; ARD, -0.68% [95% CI, -3.52% to 2.20%]; HR, 0.95 [95% CI, 0.81to1.12]) = .04 for interaction). Of 15 896 matched patients, 4837 (30.4%) were included in the KCCQ score analysis and improvements at 1 year were greater in patients with a prescription for a RAS inhibitor vs those with no prescription (median, 33.3 [interquartile range, 14.2 to 51.0] vs 31.3 [interquartile range, 13.5 to 51.1], respectively; difference in improvement, 2.10 [95% CI, 0.10 to 4.06]; P < .001), but the effect size was not clinically meaningful.CONCLUSIONS AND RELEVANCE Among patients who underwent TAVR, receiving a prescription for a RAS inhibitor at hospital discharge compared with no prescription was significantly associated with a lower risk of mortality and heart failure readmission. However, due to potential selection bias, this finding requires further investigation in randomized trials.