Treatment with insulin is associated with worse outcome in patients with chronic heart failure and diabetes
Treatment with insulin is associated with worse outcome in patients with chronic heart failure and diabetes
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DOI：
10.1002/ejhf.1146
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发表时间：
2018-05-01
影响因子：
18.2
通讯作者：
Latini, Roberto
中科院分区：
文献类型：
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作者：
Cosmi, Franco;Shen, Li;Latini, Roberto
旨在多达三分之一的糖尿病和心力衰竭(HF)患者接受胰岛素治疗。由于胰岛素导致钠滞留和低血糖，它的使用可能与更糟糕的结果相关。方法和结果我们检查了两个数据集：来自四个大型随机试验的24012名心力衰竭患者和一个管理数据库，其中有400万人，其中103857人患有心力衰竭。在前者中，生存是使用COX比例风险模型来检查的，该模型调整了基线变量，并分别调整了倾向评分。精细灰色竞争风险回归模型用于评估心力衰竭的住院风险。对于后者，进行了嵌套在基于人群的队列研究中的病例对照研究，并进行了倾向评分。在所有试验中，糖尿病的患病率从25.5%到29.5%不等。随机将24.4%至34.5%的糖尿病患者单独使用胰岛素或与口服降血糖药物联合使用。有糖尿病的患者与无糖尿病的患者相比，心力衰竭患者的各种原因死亡率和住院率更高，其中服用胰岛素的患者最高[全因死亡倾向积分合并危险比1.27(1.16-1.38)，心力衰竭住院1.23(1.13-1.33)]。在行政登记中，胰岛素处方与全因死亡[优势比(OR)2.02，95%可信区间(CI)1.87-2.19]和心力衰竭再住院(OR 1.42，95%可信区间1.32-1.53)的高风险相关。结论胰岛素的使用是否与心力衰竭的不良结局相关有待进一步的对照试验研究，以及是否有可能为心力衰竭和2型糖尿病患者提供更安全的替代降糖治疗。
Aims Up to one-third of patients with diabetes mellitus and heart failure (HF) are treated with insulin. As insulin causes sodium retention and hypoglycaemia, its use might be associated with worse outcomes.Methods and results We examined two datasets: 24 012 patients with HF from four large randomized trials and an administrative database of 4 million individuals, 103 857 of whom with HF. In the former, survival was examined using Cox proportional hazards models adjusted for baseline variables and separately for propensity scores. Fine-Gray competing risk regression models were used to assess the risk of hospitalization for HF. For the latter, a case-control nested within a population-based cohort study was conducted with propensity score. Prevalence of diabetes mellitus at study entry ranged from 25.5% to 29.5% across trials. Insulin alone or in combination with oral hypoglycaemic drugs was prescribed at randomization to 24.4% to 34.5% of the patients with diabetes. The rates of death from any cause and hospitalization for HF were higher in patients with vs. without diabetes, and highest of all in patients prescribed insulin [propensity score pooled hazard ratio for all-cause mortality 1.27 (1.16-1.38), for HF hospitalization 1.23 (1.13-1.33)]. In the administrative registry, insulin prescription was associated with a higher risk of all-cause death [odds ratio (OR) 2.02, 95% confidence interval (CI) 1.87-2.19] and rehospitalization for HF (OR 1.42, 95% CI 1.32-1.53).Conclusions Whether insulin use is associated with poor outcomes in HF should be investigated further with controlled trials, as should the possibility that there may be safer alternative glucose-lowering treatments for patients with HF and type 2 diabetes mellitus.