Effects of statin and antiplatelet therapy noncompliance and intolerance on patient outcomes following vascular surgery.
Effects of statin and antiplatelet therapy noncompliance and intolerance on patient outcomes following vascular surgery.
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他汀类药物和抗血小板治疗不依从和不耐受对血管手术后患者预后的影响。
DOI：
10.1016/j.jvs.2019.07.063
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发表时间：
2020
影响因子：
4.3
通讯作者：
Beck,AdamW
中科院分区：
文献类型：
--
作者：
Moore,JohnstonL;McFarland,GraemeE;Novak,Zdenek;Patterson,MarkA;Haverstock,Brent;Passman,MarcA;Spangler,EmilyL;Pearce,BenjaminJ;Beck,AdamW
目的已有研究评价了他汀类药物和抗血小板药物(APA)对周围动脉疾病患者的疗效。尽管他汀类药物和APA的使用益处已得到很好的描述，但对不依从性患者或因不耐受而无法服药的患者的具体结果的研究很少。在这里，我们检查对他汀类药物和APA不耐受的患者的结果，并将其与依从性或不依从性这些治疗的患者进行比较。方法纳入2005年至2018年在血管质量倡议登记中接受治疗的患者。数据丢失或在手术后30天内死亡的患者被移除。如果患者之前在出院时被开了药物，但在一年的随访中没有服用，或者如果患者在登记中被报告为不符合，则被认为是不依从性。如果列出的药物不耐受被定义为“不，出于医疗原因”，死亡率数据使用社会保障死亡指数确定，该指数定期与血管质量倡议登记交叉参考。结果我们确定了105,628名符合我们纳入标准的患者。他汀类药物不耐受在出院时为2.3%，在1年随访时为2.1%，其中0.7%在所有阶段都被列为不耐受。与他汀类药物不耐受风险增加相关的因素包括女性(P=.001)、出院APA不耐受(P=.004)、保险状况(非美国保险)(P<；.001)、出院APA不合规(P=.019)和出院血管紧张素转换酶抑制剂不合规(P=.005)。他汀类药物依从性的患者5年后存活率为91%，而不顺从性患者和不耐受患者的5年存活率分别为87%和87%(P<；.001)。在所有登记队列中，他汀类药物不耐受患者与不依从性患者的生存曲线相似。他汀类药物的不依从性与APA药物的不依从性相关(R=0.16，P<；.001)。与他汀类药物不依从性增加相关的因素包括术前活动状态(需要协助)(P=.039)、女性(P<；.001)、外周血管介入(P<；.001)或腹股沟下开放搭桥手术(P=.001)、出院状态(到疗养院)(P=1.006)和保险(自费)(P<；.001)。结论不服用他汀类和APA类药物的患者，无论原因如何，其5年生存率均显著降低。重要的是，在所有登记队列中，被注意到不耐受的患者与不顺从的患者有相似的生存曲线。不耐受的患者可能受益于尝试改变他汀类药物的剂量、类型(亲水性与亲脂性)，或从PCSK9抑制剂等新药物中受益。
ObjectivePrior studies have evaluated the effects of statin and antiplatelet agent (APA) medications on patients with peripheral arterial disease. Although the benefits of statin and APA use are well-described, there is a paucity of research into the specific outcomes of patients who are not compliant or those who are unable to take the medication owing to intolerance. Here we examine the outcomes of patients intolerant to statin and APA and compare them with patients who are compliant or noncompliant with these therapies.MethodsPatients treated from 2005 to 2018 in the Vascular Quality Initiative registry were included. Patients with missing data or deaths within 30 days of procedure were removed. Patients were considered noncompliant if they were previously prescribed a medication at discharge but were not taking it at 1-year follow-up or if the patient was reported to be noncompliant in the registry. Medication intolerance was defined if listed as “no, for medical reasons,” and mortality data were ascertained using the Social Security Death Index, which is regularly cross-referenced to the Vascular Quality Initiative registry.ResultsWe identified 105,628 patients who met our inclusion criteria. Statin intolerance was noted in 2.3% at discharge and 2.1% at the 1-year follow-up, with 0.7% listed as intolerant at all stages. Factors associated with increased risk of intolerance to statins included female gender (P= .001), discharge APA intolerance (P= .004), insurance status (non-U.S. insurance) (P< .001), discharge APA noncompliance (P= .019), and discharge angiotensin converting enzyme inhibitor noncompliance (P= .005). Patients who were compliant with statins showed a 91% survival at 5 years vs 87% survival in noncompliant patients and 87% in intolerant patients at 5 years (P< .001). Patients with statin intolerance have a similar survival curve as noncompliant patients across all registry cohorts. Noncompliance with statins was correlated with noncompliance with APA medications (R = 0.16,P< .001). Factors associated with increased risk of statin noncompliance included preoperative ambulatory status (requiring assistance) (P= .039), female sex (P< .001), peripheral vascular intervention (P< .001) or infrainguinal open bypass procedure surgery (P= .001), discharge status (to nursing home) (P= .006) and insurance (self-pay) (P< .001).ConclusionsPatients not taking statin and APA medications have a substantially decreased 5-year survival irrespective of the reason for not taking. Importantly, patients noted to be intolerant have a similar survival curve as noncompliant patients across all registry cohorts. Intolerant patients may benefit from attempts to alter statin dose, type (hydrophilic vs lipophilic), or from newer agents such as PCSK9 inhibitors.