Polypill strategy for the evidence-based management of heart failure with reduced ejection fraction in an underserved patient population

项目总结/摘要 心力衰竭在美国构成了一个主要的公共卫生挑战， 在非白人个体和低社会经济地位（SES）的个体中。越来越多的 药物已被证明可改善射血分数降低的心力衰竭患者的生存率 （HFrEF）。指南指导的药物治疗（GDMT）包括β-受体阻滞剂、血管紧张素 转化酶抑制剂、血管紧张素受体阻断剂、血管紧张素受体-脑啡肽酶抑制剂，和 盐皮质激素受体拮抗剂。当联合使用时，这些药物可以减少所有原因的 死亡率> 50%。然而，不到25%的合格患者接受3种或更多种这些药物， 任何剂量，低SES个体的利用率特别低。 复合药丸是指一种固定剂量的药物组合在一个单一的药丸，旨在减少药丸负担， 提高粘附性。复方药丸策略提供了一种方法，通过这种方法，可以使用多种药物进行治疗。 在疾病的早期阶段方便地启动，增加了随着时间的推移累积的总体治疗益处。 这在患者由于高成本、频繁的 实验室测试，并需要多次随访。 我们提出了一个单中心的，务实的试验，以息肉为基础的战略，治疗HFrEF在低， 收入，种族多样化的人口。我们将入组175名患有HFrEF（左心室射血分数）的成人 [LVEF] < 40%）在帕克兰医院接受治疗，未接受指南指导的最佳目标剂量 在德克萨斯州达拉斯的一家大型县医院接受治疗。受试者将随机接受复方制剂 或常规护理。研究的主要终点是LVEF的变化，关键次要结局将是 循环NT-proBNP水平、生活质量、6分钟步行距离和对 在12个月时进行指南指导的药物治疗。我们假设使用基于息肉的策略， HFrEF是可行的，可改善左心室收缩功能、NT-proBNP水平、生活质量， 与常规护理相比，坚持目标剂量指南指导的药物治疗。

Project Summary/Abstract Heart failure poses a major public health challenge in the United States, with growing prevalence particularly among non-white individuals and individuals of low socioeconomic status (SES). An expanding number of medications have been shown to improve survival in patients with heart failure with reduced ejection fraction (HFrEF). The list of guideline-directed medical therapies (GDMT) includes beta-blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitors, and mineralocorticoid receptor antagonists. When used in combination, these medications reduce all-cause mortality by > 50%. Nonetheless, fewer than 25% of eligible patients receive 3 or more of these medications, at any dose, with particularly low rates of utilization among low SES individuals. The polypill refers to a fixed-dose combination of medications in a single pill, aimed at reducing pill burden and improving adherence. The polypill strategy offers a means by which therapy with multiple medications can be conveniently initiated at an early stage of disease, increasing the overall therapeutic benefit accrued over time. This is particularly relevant in settings where patients experience barriers to care due to high costs, frequent lab tests, and need for multiple follow up visits. We propose a single-center, pragmatic trial of a polypill-based strategy for the treatment of HFrEF in a low- income, racially-diverse population. We will enroll 175 adults with HFrEF (left ventricular ejection fraction [LVEF] < 40%) receiving care at Parkland Hospital who are not on optimal, target dose of guideline-directed medical therapy at a large county hospital in Dallas, TX. Participants will be randomized to receiving a polypill or usual care. The primary endpoint of the study is the change in LVEF, and the key secondary outcome will be change in circulating NT-proBNP levels, quality-of-life, six minute walk distance, and the adherence to guideline directed medical therapy at 12 months. We hypothesize that use of a polypill-based strategy in HFrEF will be feasible and lead to improved left ventricular systolic function, NT-proBNP levels, quality of life, and adherence to target dose guideline directed medical therapy compared with usual care.