Polypharmacy, Adverse Outcomes, and Treatment Effectiveness in Patients ≥75 With Atrial Fibrillation
Polypharmacy, Adverse Outcomes, and Treatment Effectiveness in Patients ≥75 With Atrial Fibrillation
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DOI：
10.1161/jaha.119.015089
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发表时间：
2020-06-02
影响因子：
5.4
通讯作者：
Alonso, Alvaro
中科院分区：
文献类型：
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作者：
Chen, Nemin;Alam, Aniqa B.;Alonso, Alvaro
背景：多种药物在患有慢性疾病（包括房颤）的老年人中非常普遍。多种药物治疗对老年AF患者不良结局和治疗效果的影响仍未得到解决。方法和结果：我们研究了2007-2015年MarketScan Medicare补充数据库中登记的338810例≥ 75岁的AF患者。根据门诊药房索赔，多种药物治疗定义为房颤诊断时≥ 5张有效处方（定义为国际疾病分类第九版临床修改[ICD-9-CM]代码）。根据住院、门诊和药房索赔定义AF治疗（口服抗凝、心律和心率控制）和心血管终点（缺血性中风、出血、心力衰竭）。多变量考克斯模型用于评估多种药物与心血管终点的相关性以及多种药物与AF治疗之间与心血管终点的相互作用。多种药物的患病率为52%。与未接受多种药物治疗的患者相比，接受多种药物治疗的患者发生大出血（风险比[HR]，1.16; 95%CI，1.12-1.20）和心力衰竭（HR，1.33; 95%CI，1.29-1.36）的风险增加，但缺血性卒中（HR，0.96; 95%CI，0.92-1.00）的风险未增加。多药状态并不总是改变口服抗凝剂的有效性。节律控制（与速率控制相比）在预防未接受多种药物治疗的患者因心力衰竭住院方面更有效（HR，0.87; 95% CI，0.76-0.99）（HR，0.98; 95% CI，0.91-1.07;相互作用P=0.02）。多药治疗在≥ 75岁的房颤患者中很常见，与不良结局相关，并可能改变房颤治疗的有效性。AF>= 75的患者中优化多种药物治疗的管理可能会改善结局。
BACKGROUND: Polypharmacy is highly prevalent in elderly people with chronic conditions, including atrial fibrillation (AF). The impact of polypharmacy on adverse outcomes and on treatment effectiveness in elderly patients with AF remains unaddressed.METHODS AND RESULTS: We studied 338 810 AF patients >= 75 years of age enrolled in the MarketScan Medicare Supplemental database in 2007-2015. Polypharmacy was defined as >= 5 active prescriptions at AF diagnosis (defined by the presence of International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes) based on outpatient pharmacy claims. AF treatments (oral anticoagulation, rhythm and rate control) and cardiovascular end points (ischemic stroke, bleeding, heart failure) were defined based on inpatient, outpatient, and pharmacy claims. Multivariable Cox models were used to estimate associations of polypharmacy with cardiovascular end points and the interaction between polypharmacy and AF treatments in relation to cardiovascular end points. Prevalence of polypharmacy was 52%. Patients with polypharmacy had increased risk of major bleeding (hazard ratio [HR], 1.16; 95% CI, 1.12-1.20) and heart failure (HR, 1.33; 95% CI, 1.29-1.36) but not ischemic stroke (HR, 0.96; 95% CI, 0.92-1.00), compared with those not receiving polypharmacy. Polypharmacy status did not consistently modify the effectiveness of oral anticoagulants. Rhythm control (versus rate control) was more effective in preventing heart failure hospitalization in patients not receiving polypharmacy (HR, 0.87; 95% CI, 0.76-0.99) than among those with polypharmacy (HR, 0.98; 95% CI, 0.91-1.07; P=0.02 for interaction).CONCLUSION: Polypharmacy is common among patients >= 75 with AF, is associated with adverse outcomes, and may modify the effectiveness of AF treatments. Optimizing management of polypharmacy in AF patients >= 75 may lead to improved outcomes.