Effectiveness of angiotensin-neprilysin inhibitor treatment versus renin-angiotensin system blockade in older adults with heart failure in clinical care
Effectiveness of angiotensin-neprilysin inhibitor treatment versus renin-angiotensin system blockade in older adults with heart failure in clinical care
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DOI：
10.1136/heartjnl-2021-319405
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发表时间：
2021-09-01
期刊：
影响因子：
5.7
通讯作者：
Schneeweiss, Sebastian
中科院分区：
文献类型：
--
作者：
Desai, Rishi J.;Patorno, Elisabetta;Schneeweiss, Sebastian
目的 评估血管紧张素受体 - 脑啡肽酶抑制剂（ARNI）相较于单独使用肾素 - 血管紧张素系统（RAS）阻滞剂在射血分数降低的心力衰竭（HFrEF）老年患者中的有效性。方法 我们利用美国医疗保险按服务收费索赔数据（2014 - 2017年）进行了一项队列研究。在两个队列中确定了年龄≥65岁的HFrEF患者：（1）单独使用ARNI或RAS阻滞剂（血管紧张素转换酶抑制剂，ACEI；或血管紧张素受体阻滞剂，ARB）的起始治疗者；（2）从ACEI转换为ARNI或ARB的换药者。通过倾向评分精细分层加权对71种暴露前特征进行调整后，计算复合结局（首次心力衰竭恶化事件发生时间或全因死亡）的风险比（HR）及95%置信区间，以及1年受限平均生存时间（RMST）差值及95%置信区间。对起始治疗者队列和换药者队列的所有分析均分别进行，然后使用固定效应进行合并。结果 共纳入51208例患者，平均年龄76岁，其中ARNI组有16193例。在起始治疗者中，调整后的ARNI与单独使用RAS阻滞剂相比的HR为0.92（95%置信区间0.84 - 1.00），在换药者中为0.79（95%置信区间0.74 - 0.85），合并估计值为0.84（95%置信区间0.80 - 0.89）。调整后的1年RMST差值（95%置信区间）在起始治疗者队列中为4天（ - 1 - 9天），在换药者队列中为12天（8 - 17天），汇总估计值为9天（6 - 12天），有利于ARNI。结论 在患有HFrEF的老年患者中，与单独使用RAS阻滞剂相比，ARNI治疗与复合有效性终点的较低风险相关。
Objective To evaluate the effectiveness of angiotensin receptor-neprilysin inhibitor (ARNI) versus renin-angiotensin system (RAS) blockade alone in older adults with heart failure with reduced ejection fraction (HFrEF). Methods We conducted a cohort study using US Medicare fee-for-service claims data (2014-2017). Patients with HFrEF >= 65 years were identified in two cohorts: (1) initiators of ARNI or RAS blockade alone (ACE inhibitor, ACEI; or angiotensin receptor blocker, ARB) and (2) switchers from an ACEI to either ARNI or ARB. HR with 95% CI from Cox proportional hazard regression and 1-year restricted mean survival time (RMST) difference with 95% CI were calculated for a composite outcome of time to first worsening heart failure event or all-cause mortality after adjustment for 71 pre-exposure characteristics through propensity score fine-stratification weighting. All analyses of initiator and switcher cohorts were conducted separately and then combined using fixed effects. Results 51 208 patients with a mean age of 76 years were included, with 16 193 in the ARNI group. Adjusted HRs comparing ARNI with RAS blockade alone were 0.92 (95% CI 0.84 to 1.00) among initiators and 0.79 (95% CI 0.74 to 0.85) among switchers, with a combined estimate of 0.84 (95% CI 0.80 to 0.89). Adjusted 1-year RMST difference (95% CI) was 4 days in the initiator cohort (-1 to 9) and 12 days (8 to 17) in the switcher cohort, resulting in a pooled estimate of 9 days (6 to 12) favouring ARNI. Conclusion ARNI treatment was associated with lower risk of a composite effectiveness endpoint compared with RAS blockade alone in older adults with HFrEF.