Association Between Intensity of Statin Therapy and Mortality in Patients With Atherosclerotic Cardiovascular Disease
Association Between Intensity of Statin Therapy and Mortality in Patients With Atherosclerotic Cardiovascular Disease
复制标题
DOI：
10.1001/jamacardio.2016.4052
复制
发表时间：
2017-01-01
期刊：
影响因子：
24
通讯作者：
Heidenreich, Paul A.
中科院分区：
文献类型：
--
作者：
Rodriguez, Fatima;Maron, David J.;Heidenreich, Paul A.
重要性：高强度他汀类药物被推荐用于动脉粥样硬化性心血管疾病（ASCVD）的二级预防。然而，他汀类药物治疗，特别是高强度他汀类药物治疗，在ASCVD患者中应用不足。目的探讨退伍军人事务卫生保健系统中全因死亡率与他汀类药物治疗强度的关系。设计、环境和参与者：对2013年4月1日至2014年4月1日在退伍军人事务卫生保健系统治疗的年龄在21至84岁的ASCVD患者进行回顾性队列分析。纳入的患者在过去2年的2个或多个不同日期有1个或多个ASCVD国际疾病分类第九次修订代码。他汀类药物治疗的强度由2013年美国心脏病学会/美国心脏协会指南定义，并定义为在过去6个月内使用处方。如果患者在过去5年内服用了较高的他汀类药物剂量，则排除在外。主要结局和测量主要结局是根据接受高强度他汀类药物的倾向调整的全因死亡。结果：研究样本包括509 766名基线时符合条件的ASCVD成人（平均[SD]年龄68.5[8.8]岁；499 598名男性和10 168名女性），其中150 928人（29.6%）接受高强度他汀类药物治疗，232 293人（45.6%）接受中强度他汀类药物治疗，33 920人（6.7%）接受低强度他汀类药物治疗，92 625人（18.2%）不接受他汀类药物治疗。在平均492天的随访期间，他汀类药物治疗强度与死亡率之间存在分级相关性，接受高强度他汀类药物治疗的1年死亡率为4.0%（126 139例中有5103例），接受中等强度他汀类药物治疗的1年死亡率为4.8%（200 709例中有9703例），接受低强度他汀类药物治疗的1年死亡率为5.7%（28 765例中有1632例），未接受他汀类药物治疗的1年死亡率为6.6%（73 728例中有4868例）（P < 0.001）。在调整接受高强度他汀类药物的倾向后，接受高强度和中等强度他汀类药物的患者的死亡率风险比为0.91 （95% CI, 0.88-0.93）。高强度与中等强度他汀类药物的获益程度相似，事件队列风险比为0.93 （95% CI, 0.85-1.01）。对于76 - 84岁的患者，风险比为0.91 （95% CI, 0.87-0.95）。与接受次最大剂量的患者相比，接受最大剂量高强度他汀类药物治疗的患者死亡率较低（风险比，0.90;95% CI, 0.87-0.94）。结论和相关性我们在全国ASCVD患者样本中发现他汀类药物治疗强度与死亡率之间存在分级相关性。与中等强度的他汀类药物相比，高强度的他汀类药物与小但显著的生存优势相关，即使在老年人中也是如此。最大剂量的高强度他汀类药物与进一步的生存获益相关。
IMPORTANCE High-intensity statin therapy is recommended for the secondary prevention of atherosclerotic cardiovascular disease (ASCVD). Nevertheless, statin therapy in general, and high-intensity statin therapy in particular, is underused in patients with established ASCVD.OBJECTIVE To determine the association between all-cause mortality and intensity of statin therapy in the Veterans Affairs health care system.DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort analysis was conducted of patients aged 21 to 84 years with ASCVD treated in the Veterans Affairs health care system from April 1, 2013, to April 1, 2014. Patients who were included had 1 or more International Classification of Diseases, Ninth Revision codes for ASCVD on 2 or more different dates in the prior 2 years.EXPOSURES Intensity of statin therapy was defined by the 2013 American College of Cardiology/American Heart Association guidelines, and use was defined as a filled prescription in the prior 6 months. Patients were excluded if they were taking a higher statin dose in the prior 5 years.MAIN OUTCOMES AND MEASURES The primary outcome was death from all causes adjusted for the propensity to receive high-intensity statins.RESULTS The study sample included 509 766 eligible adults with ASCVD at baseline (mean [SD] age, 68.5 [8.8] years; 499 598 men and 10 168 women), including 150 928 (29.6%) receiving high-intensity statin therapy, 232 293 (45.6%) receiving moderate-intensity statin therapy, 33 920 (6.7%) receiving low-intensity statin therapy, and 92 625 (18.2%) receiving no statins. During a mean follow-up of 492 days, there was a graded association between intensity of statin therapy and mortality, with 1-year mortality rates of 4.0%(5103 of 126 139) for those receiving high-intensity statin therapy, 4.8%(9703 of 200 709) for those receiving moderate-intensity statin therapy, 5.7%(1632 of 28 765) for those receiving low-intensity statin therapy, and 6.6%(4868 of 73 728) for those receiving no statin (P < .001). After adjusting for the propensity to receive high-intensity statins, the hazard ratio for mortality was 0.91 (95% CI, 0.88-0.93) for those receiving high-vs moderate-intensity statins. The magnitude of benefit of high-vs moderate-intensity statins was similar, for an incident cohort hazard ratio of 0.93 (95% CI, 0.85-1.01). For patients aged 76 to 84 years, the hazard ratio was 0.91 (95% CI, 0.87-0.95). Patients treated with maximal doses of high-intensity statins had lower mortality (hazard ratio, 0.90; 95% CI, 0.87-0.94) compared with those receiving submaximal doses.CONCLUSIONS AND RELEVANCE We found a graded association between intensity of statin therapy and mortality in a national sample of patients with ASCVD. High-intensity statins were associated with a small but significant survival advantage compared with moderate-intensity statins, even among older adults. Maximal doses of high-intensity statins were associated with a further survival benefit.