Guideline concordance of testing for hyperkalemia and kidney dysfunction during initiation of mineralocorticoid receptor antagonist therapy in patients with heart failure.
Guideline concordance of testing for hyperkalemia and kidney dysfunction during initiation of mineralocorticoid receptor antagonist therapy in patients with heart failure.
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DOI：
10.1161/circheartfailure.113.000709
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发表时间：
2014-01
期刊：
影响因子：
--
通讯作者：
Magid DJ
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作者：
Allen LA;Shetterly SM;Peterson PN;Gurwitz JH;Smith DH;Brand DW;Fairclough DL;Rumsfeld JS;Masoudi FA;Magid DJ
盐皮质激素受体拮抗剂（MRA）可降低射血分数降低的心力衰竭（HFREF）的发病率和死亡率，但可引起高钾血症和急性肾损伤。指南建议在开始MRA之前和之后连续测量血清钾（K）和肌酐（Cr），但其发生的程度尚不清楚。使用2005-2008年3个卫生系统的电子数据，我们对490例因HFREF住院并随后开始MRA治疗的患者的实验室监测进行了回顾性分析。开始MRA时的中位年龄为73岁，37.1%为女性。螺内酯占MRA使用的99.4%。70.0%的病例在出院时进行初始动态MRA分配。在MRA开始前30天内，94.3%的患者进行了K或Cr测量。1.4%的患者开始前K>5.0 mmol/L，1.7%的患者Cr >2.5 mg/dL。在MRA开始后的7天内，在仍然存活和出院的患者中，46.5%没有K测量的证据;到30天，13.6%仍然未进行测试。患者因素解释了启动后K检验的一小部分（c-统计量0.67）。虽然在HFREF的MRA开始之前进行实验室监测是常见的，但MRA开始后的实验室监测通常不符合指南建议，即使是在并发症风险较高的患者中。鼓励使用相互承认和相互承认评估的质量改进努力还应包括处理建议的监测的机制。
Mineralocorticoid receptor antagonists (MRA) reduce morbidity and mortality in heart failure with reduced ejection fraction (HFREF), but can cause hyperkalemia and acute kidney injury. Guidelines recommend measurement of serum potassium (K) and creatinine (Cr) before and serially after MRA initiation, but the extent to which this occurs is unknown. Using electronic data from 3 health systems 2005-2008, we performed a retrospective review of laboratory monitoring among 490 patients hospitalized for HFREF who were subsequently initiated on MRA therapy. Median age at time of MRA initiation was 73 years and 37.1% were female. Spironolactone accounted for 99.4% of MRA use. Initial ambulatory MRA dispensing occurred at hospital discharge in 70.0% of cases. In the 30 days before MRA initiation, 94.3% of patients had a K or Cr measurement. Pre-initiation K was >5.0 mmol/L in 1.4% and Cr >2.5 mg/dL in 1.7%. In the 7 days after MRA initiation among patients who remained alive and out of the hospital, 46.5% had no evidence of K measurement; by 30 days, 13.6% remained untested. Patient factors explained a small portion of post-initiation K testing (c-statistic 0.67). While laboratory monitoring prior to MRA initiation for HFREF is common, laboratory monitoring following MRA initiation frequently does not meet guideline recommendations, even in patients at higher risk for complications. Quality improvement efforts that encourage the use of MRA should also include mechanisms to address recommended monitoring.