| Background: Although the angiotensin receptor neprilysin inhibitor(ARNI)sacubitril/valsartan has been recommended a first-line management for patients with heart failure with reduced ejection fraction(HFr EF).However,adoption of ARNI into clinical practice has been slow.Factors influencing use of ARNI have not been fully elucidated.Objective: To characterize treatment patterns of ARNI therapy in HFr EF patients,to analyze the factors and reasons for dosing changes and provide a reference for clinical medication.Method: This is a retrospective single-center cohort study of HFr EF patients admitted to the Department of Cardiology of Henan Provincial People’s Hospital from January 2018 to March 2019.Clinical characteristics,biomarker profiles,echocardiographic images,and baseline medication usages were collected.According to the baseline usage of ARNI/angiotensin-converting enzyme inhibitors(ACEI)/angiotensin II receptor blockers(ARB),patients were divided into ARNI group,ACEI/ARB group and Neither group.We analyzed the prescription of ARNI and compared the baseline characteristics of three groups.Clinical outcomes,systolic blood pressure(SBP),use and dose of ARNI and other HF medical therapies(β-blockers,mineralocorticoid receptor antagonists(MRA),loop diuretics)were examined at baseline and at 6-month follow-up among ARNI group.Multivariate analyses were used to analyse predictors of ARNI dose changes.Result: A total of 756 HFr EF patients who met inclusion criteria were enrolled.198(26.2%)were prescribed ARNI,395(52.2%)an ACEI/ARB,and 163(21.6%)neither.Patients prescribed ARNI were more likely to be male(72.7%,70.7%,61.4%,P<0.05),younger(52.6±14.3 years,56.7±13.8 years,62.7±11.5 years,P<0.01),NYHA degree better(I/II 49.5%,45%,39.9%,P<0.01)and had larger left ventricular end diastolic diameter(69(64,75)mm,68(62,75)mm,67(60.5,73)mm,P<0.01)and lower left ventricular ejection fraction(LVEF)(29.4±5.6%,31.5±5.9%,30.6±5.4%,P<0.01).After treatment,SBP,heart beats,NT-pro BNP were decreased significantly(P<0.01),LVEF was significantly improved(P<0.01).After treatment,the daily doses of β receptor blockers which ≥95mg increased by 6%(metoprolol succinate equivalent),daily loop diuretics dosage at 40 mg were decreased from 44.7% to 37.7%,MRA daily dosage at 20 mg changed little from 87.9% to 85.4%.Of the 198 patients under ARNI therapy,the number of initial doses of 25 mg bid,50 mg bid,100 mg bid and 200 mg bid were 38(19.1%),105(52.8%),51(25.6%)and 4(2%)respectively.8(4.0%)were up-titrated to target dose,while 103(52%)had no ARNI dose changes during the 6 months.During the follow-up,102(56.7%)had SBP ≥ 110 mm Hg(the valid number of SBP was 180),among which 6(5.9%)reached the target dose.The proportion of ARNI dose of 100 mgbid,50mgbid and 25 mgbid was 27.5%,44.1% and 6.9%,respectively.Multivariate analyses indicated that rehospitalization(OR=2.90,95%CI: 1.22～8.52,P<0.05)was an independent predictor of ARNI up-titration,SBP<100 mm Hg(OR=4.12,95%CI: 1.54～11.02,P<0.01),LVEF<30%(OR=0.28,95%CI: 0.14～0.56,P<0.01)were predictors of ARNI down-titration or withdrawal.Conclusion: Most patients initially prescribed ARNI at a lowest dose,the major part stayed still at a small dose and few titrated at the target dose.Hospitalization is a potential time for ARNI titration.The time before and after discharge makes sense.Therefore a regular outpatient follow-up values for guidelinedirected medication therapy(GDMT)and needs to be reinforced to achieve optimal benefit.The use of β-blockers increased and loop diuretics reduced simultaneously. |
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