Association of Medication Intensity and Stages of Airflow Limitation With the Risk of Hospitalization or Death in Patients With Heart Failure and Chronic Obstructive Pulmonary Disease
Association of Medication Intensity and Stages of Airflow Limitation With the Risk of Hospitalization or Death in Patients With Heart Failure and Chronic Obstructive Pulmonary Disease
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DOI：
10.1001/jamanetworkopen.2018.5489
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发表时间：
2018-12-01
影响因子：
13.8
通讯作者：
Kadam, Umesh T.
中科院分区：
文献类型：
--
作者：
Lawson, Claire A.;Mamas, Mamas A.;Kadam, Umesh T.
在心力衰竭（HF）中，慢性阻塞性肺疾病（COPD）增加了不良结局的风险，但COPD严重程度的影响尚不清楚。为了确定COPD药物治疗强度或气流限制阶段与HF患者住院或死亡风险之间的关系，设计、设置和参与者这项英国基于人群的巢式病例对照研究，采用风险集抽样，使用临床实践研究数据链接，2002年至2014年1月1日。参与者包括在家庭实践临床记录中新诊断为HF的40岁及以上患者。数据分析从2017年到2018年进行。暴露在HF患者中，将COPD患者与非COPD患者进行比较。（慢性阻塞性肺病全球倡议[GOLD]）使用自动记录的处方和常规要求的用力呼气量，按照7个药物强度水平和4个气流限制严重程度阶段对COPD患者进行分层。结果在研究期间有50114例新发HF患者（中位年龄79岁[四分位距71-85岁]; 46%为女性）。在HF患者中，COPD（18 478 [13.8%]）与死亡率（校正比值比[AOR]，1.31; 95% CI，1.26-1.36）和住院率（AOR，1.33; 95% CI，1.26-1.39）增加显著相关。3个最严重的药物强度水平显示，从完全吸入器治疗（AOR，1.17; 95% CI，1.06-1.29）到口服皮质类固醇（AOR，1.69; 95% CI，1.57-1.81）再到氧气治疗（AOR，2.82; 95% CI，2.42-3.28），死亡率显著增加。住院治疗的AOR分别为1.17（95% CI，1.03-1.33）、1.75（95% CI，1.59-1.92）和2.84（95% CI，1.22-3.63）。肺功能测定数据的可用性有限，但显示气流受限增加与死亡风险增加相关，AOR如下：FEV 1 80%或更高，1.63（95% CI，1.42-1.87）; FEV 1 50%-79%，1.69（95% CI，1.56-1.83）; FEV 1 30%-49%，2.21（95% CI，2.01-2.42）; FEV 1小于30%，2.93（95% CI，2.49-3.43）。FEV 1和住院风险之间的关联强度在FEV 1> 80%或更高的阶段之间相似。（AOR，1.48; 95% CI，1.31-1.68）至FEV 1小于30%（AOR，1.73; 95%CI，1.40-2.12）。结论和相关性在英国HF社区环境中，COPD严重程度的增加与死亡率和住院风险的增加相关。处方COPD药物强度和气流限制为针对高危人群提供了基础。
IMPORTANCE In heart failure (HF), chronic obstructive pulmonary disease (COPD) increases the risk of poor outcomes, but the effect of COPD severity is unknown. This information is important for early intervention tailored to the highest-risk groups.OBJECTIVES To determine the associations between COPD medication intensity or stage of airflow limitation and the risk of hospitalization or death in patients with HF.DESIGN, SETTING, AND PARTICIPANTS This UK population-based, nested case-control study with risk-set sampling used the Clinical Practice Research Datalink linked to Hospital Episode Statistics between January 1, 2002, to January 1, 2014. Participants included patients aged 40 years and older with a new diagnosis of HF in their family practice clinical record. Data analysis was conducted from 2017 to 2018.EXPOSURES In patients with HF, those with COPD were compared with those without it. International COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD]) guidelines were used to stratify patients with COPD by 7 medication intensity levels and 4 airflow limitation severity stages using automatically recorded prescriptions and routinely requested forced expiratory volume in 1 second (FEV1) data.MAIN OUTCOMES AND MEASURES First all-cause admission or all-cause death.RESULTS There were 50 114 patients with new HF (median age, 79 years [interquartile range, 71-85 years]; 46% women) during the study period. In patients with HF, COPD (18 478 [13.8%]) was significantly associated with increased mortality (adjusted odds ratio [AOR], 1.31; 95% CI, 1.26-1.36) and hospitalization (AOR, 1.33; 95% CI, 1.26-1.39). The 3 most severe medication intensity levels showed significantly increasing mortality associations from full inhaler therapy (AOR, 1.17; 95% CI, 1.06-1.29) to oral corticosteroids (AOR, 1.69; 95% CI, 1.57-1.81) to oxygen therapy (AOR, 2.82; 95% CI, 2.42-3.28). The respective estimates for hospitalization were AORs of 1.17 (95% CI, 1.03-1.33), 1.75 (95% CI, 1.59-1.92), and 2.84 (95% CI, 1.22-3.63). Availability of spirometry data was limited but showed that increasing airflow limitation was associated with increased risk of mortality, with the following AORs: FEV1 80% or more, 1.63 (95% CI, 1.42-1.87); FEV1 50% to 79%, 1.69 (95% CI, 1.56-1.83); FEV1 30% to 49%, 2.21 (95% CI, 2.01-2.42); FEV1 less than 30%, 2.93 (95% CI, 2.49-3.43). The strength of associations between FEV1 and hospitalization risk were similar among stages ranging from FEV1 80% or more (AOR, 1.48; 95% CI, 1.31-1.68) to FEV1 less than 30% (AOR, 1.73; 95% CI, 1.40-2.12).CONCLUSIONS AND RELEVANCE In the UK HF community setting, increasing COPD severity was associated with increasing risk of mortality and hospitalization. Prescribed COPD medication intensity and airflow limitation provide the basis for targeting high-risk groups.