RESUMO
Background: This study aimed to assess the prescribing patterns of evidence-based pharmacotherapy and their association with clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF) in Thailand. Methods: A retrospective cohort study of patients with HFrEF was conducted. Treatment with a ß-blocker and renin-angiotensin system inhibitors (RASIs) with or without mineralocorticoid receptor antagonists (MRAs) at discharge was regarded as guideline-directed medical therapy (GDMT). All others were considered non-GDMT. The primary endpoint was the composite of all-cause mortality or heart failure (HF) rehospitalization. Inverse-probability-treatment-weighted adjusted Cox proportional hazard models were used to examine the treatment effects. Results: In total, 653 patients with HFrEF (mean age 64.1 ± 14.3 years; 55.9% male) were included. GDMT with ß-blockers and RASIs with or without MRAs was prescribed at a rate of 35.4%. During a median of 1-year follow-up, 167 patients (27.5%) had a composite event, 81 patients (13.3%) had all-cause mortality, and 109 patients (18.0%) had HF rehospitalization. Patients treated with GDMT at discharge showed significantly lower rates of the primary endpoint (adjusted hazard ratio [HR] 0.63; 95% CI 0.44-0.89; p = 0.009) compared with patients who did not receive GDMT. The use of GDMT was also associated with a significantly lower risk of all-cause mortality (adjusted HR 0.59; 95% CI 0.36-0.98; p = 0.045) and HF rehospitalization (adjusted HR 0.65; 95% CI 0.43-0.96; p = 0.031). Conclusions: For HFrEF treatment, GDMT initiation at hospital discharge was associated with a significantly reduced risk of all-cause mortality and HF rehospitalization. Nevertheless, prescribing GDMT remains underused, and it could be encouraged to improve HF outcomes in real-world settings.
RESUMO
BACKGROUND: Digoxin is used to control heart rate in patients with heart failure (HF) and atrial fibrillation (AF). However, its use is often limited in older patients, as they are prone to digoxin toxicity. This study aimed to determine the prevalence of digoxin use, investigate the factors associated with digoxin use, and explore the association between digoxin use and clinical outcomes in older Thai patients with HF and AF. METHODS: This cross-sectional study used data obtained from an electronic medical records database. We performed logistic regression analysis to determine the prevalence of digoxin use at index discharge and the factors associated with its use. The Cox proportional hazard model was used to determine the association of all-cause mortality and HF rehospitalization with digoxin use. RESULTS: Of the 640 patients assessed, 107 (16.72%) were prescribed digoxin before discharge. The factors negatively associated with digoxin use included high serum creatinine level (adjusted odds ratio [AOR] =0.38; 95% confidence interval [CI], 0.22-0.65) and ischemic heart disease (IHD) (AOR=0.52; 95% CI, 0.30-0.88). The factors positively associated with digoxin use were the use of diuretics (AOR=2.65; 95% CI, 1.60-4.38) and mineralocorticoid receptor antagonists (MRAs) (AOR=2.24; 95% CI, 1.18-4.27). We observed no significant association between digoxin use and clinical outcomes (adjusted hazard ratio=1.00; 95% CI, 0.77-1.30). CONCLUSION: Digoxin use was prevalent among older patients with HF and AF. Patients with high serum creatinine or IHD were less likely to be prescribed digoxin, whereas those using diuretics or MRAs were more likely to be prescribed digoxin. Although digoxin use was not uncommon among older patients, it was prescribed with caution among Thai patients hospitalized with HF and AF.
RESUMO
BACKGROUND: Optimal medical therapy (OMT) is recommended for patients with acute coronary syndrome (ACS) at discharge. This study aimed to assess temporal trends of OMT prescription as a five-drug regimen at discharge and its association with clinical outcomes in patients with ACS in Thailand. METHODS: A retrospective cohort study was conducted in a tertiary-care medical center in Thailand. Data were collected from an electronic medical database. Patients were categorized into OMT or non-OMT groups based on their discharge medications. OMT was defined as a combination of aspirin and P2Y12 inhibitors, statins, beta-blockers, and angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers. The primary outcome was 1-year all-cause mortality. The secondary outcome was major adverse cardiac events (MACE) which was defined as a composite of non-fatal myocardial infarction, non-fatal stroke, and all-cause mortality. The prescription trends were also estimated. A multivariate Cox's proportional hazard model was used to assess the association of OMT prescriptions at discharge with all-cause mortality and MACE. RESULTS: A total of 3531 patients discharged with ACS [mean age, 69.5 (SD 12.4) years; 58.3% male] were identified. Only 42.6% were discharged with OMT. The rates of OMT prescriptions did not change over time. However, the prescription of OMT with high-intensity statin was significantly increased from 5.0% in 2013 to 38.3% in 2018 (p for trend <0.001). Multivariable analyses indicated that OMT significantly reduced all-cause mortality (adjusted HR: 0.77; 95%CI: 0.63-0.95; p=0.012) and MACE (adjusted HR 0.84; 95%CI: 0.71-0.99; p = 0.044). Subgroup analysis indicated that patients receiving OMT with high-intensity statins exhibited survival benefits (adjusted HR: 0.72; 95%CI: 0.56-0.92; p=0.008). CONCLUSIONS: The five-drugs comprising OMT were associated with a reduction in all-cause mortality and MACE in patients with ACS. Nevertheless, OMT prescribing remains underused and could be enhanced in the real-world setting.
