The Current Status Of Drug Treatment And Clinical Prognosis In Patients With Chronic Heart Failure With Reduced Ejection Fraction

[Background]Heart failure(HF)is the severe manifestation or terminal stage of various heart diseases,with a high morbidity,readmission rate and mortality.According to the left ventricular ejection fraction,the heart failure can be divided into heart failure with reduced ejection fraction(HFrEF,LVEF<40%),heart failure with preserved ejection fraction(HFpEF,LVEF≥50%)and heart failure with mid-range ejection fraction(HFmrEF,LVEF40～49%).For patients with HFrEF,drug therapy is recommended in domestic and foreign guidelines,which is the use of Renin-angiotensin system inhibitor,includes angiotensin converting enzyme inhibitor(ACEI)or angiotensin II receptor blocker(ARB)or angiotensin receptor neprilysin inhibitor(ARNI),combining with beta-blocker,using mineralocorticoid receptor antagonist(MRA)in adaptive patients,and using diuretics in needed.Guidelines recommend patients with EFrEF be treated with multiple medications to improve the symptoms and prognosis and to reduce readmission rate and mortality.However,in real clinical practice,there is still a big gap between the current status and the guideline recommendation,no matter in terms of the use of drug types or drug dose adjustment,and the current status of clinical prognosis is various.Thus,it is imperative to investigate the current status of drug treatment and clinical prognosis for patients with HFrEF,in order to guide the clinical diagnosis,treatment and management of patients with HFrEF better.[Objective]The objectives of this study were to investigate the application of drug treatment and clinical prognosis in patients with HFrEF,analyze the current status of drug treatment of patients with HFrEF,and to compare and analyze the influencing factors of standardized drug treatment and clinical prognosis.[Methods]This study was a prospective,observational study.A total of 110 patients who were hospitalized in the department of cardiology in the first affiliated hospital of kunming medical university during July 2019 to September 2020 were enrolled in this study.The information involving patient baseline clinical data,electrocardiogram,laboratory examinations,ultrasonic cardiogram,serum ST2 and drug treatment were collected.The quality of life scale(EQ-5D,EQ-VAS and MLHFQ)and Morisky medication adherence scale(MMAS-8)were used to score the patients.Follow-up were implemented at 3months and 6months after discharge,the scores of quality of life scale and medication adherence scale were evaluated again and the changes in the scores of sequence scale were compared;Drug treatment was collected during follow-up,the patients were divided into groups based on whether the dose reached the target(100%target dose group,50%-99%target dose group,<50%target dose group),the clinical endpoint events(including all-cause death and all-cause readmission)were observed,and patients were divided into groups according to the occurrence of clinical endpoint events.Patients with all-cause death or all-cause readmission were classified as poor prognosis group,while patients with neither of them were classified as good prognosis group,Compare and analyze the influencing factors of drug treatment and clinical prognosis.[Results]1.The average age of 110 HFrEF patients was(57.9±14.1)years old,among which 65(58.6%)were males,63.6%(70/110)of the patients lived in other cities of Yunnan Province,90.9%(100/110)were Han nationality,and 49.1%(54/110)were farmers.The main causes were dilated cardiomyopathy[44.5%(49/110)],coronary heart disease[25.2%(28/110)],hypertension[16.2%(18/110)],valvular heart disease[7.3%(8/110)],and alcoholic cardiomyopathy[3.6%(4/110)].The common inducements were fatigue[39.1%(43/110)],infection[21.8%(17/110)],myocardial ischemia[16.4%(18/110)],poor treatment compliance[7.3%(8/110)],and arrhythmia[6.4%(7/110)].The mortality rate during hospitalization was 3.6%(4/110).3 months after discharge,1 patient was lost to follow-up,and 6 months after discharge,8 patients were lost to follow-up,a total of 9 cases were lost to follow-up,and the total loss rate was 8.2%(9/110).2.At discharge,the utilization rates of ACEI/ARB/ARNI,beta-blocker and MRA in HFREF patients were 73.6%,82.1%and 89.6%,respectively.The utilization rate of ACEI/ARB/ARNI,beta-blocker and MRA was 59.4%.As for the dose of ACEI/ARB/ARNI,only 12.8%of the patients reached the target dose recommended by the guidelines,42.3%of the patients received 50%～99%of the target dose,and 44.9%of the patients received<50%of the target dose.As for the dose of beta-blocker,only 1 patient(1.1%)reached the target dose,13.8%patients received 50%～99%target dose,and 85.1%patients received<50%target dose.Among the dose of spironolactone,97.9%of the patients reached the target dose,while only 2 patients(2.1%)did not reach the target dose,and their doses were all 50%～99%of the target dose.3.At discharge,among the patients who did not use ACEI/ARB/ARNI,hypotension,deterioration of renal function and Without a prescription were the main reasons.Among patients who did not use beta-blocker,the leading causes were bradycardia,hypotension,atrioventricular block and non-prescription.The use rate was lower than that at discharge.4.At follow-up after 3 months,the utilization rates of ACEI/ARB/ARNI,beta-blocker and MRA were 69.8%,79.2%and 84.4%,respectively;The utilization rate of ACEI/ARB/ARNI,beta-blocker and MRA was 56.3%.At follow-up after 3 months,the main factors affecting drug treatment were still hypotension,bradycardia,deterioration of renal function and non-prescription.3.7%(6/105)of the patients realized that their symptoms were improving and stopped taking the drug.One case(1.0%)of the patients stopped taking the drug after discharge due to the difficulty in purchasing the drug due to the remote location.At follow-up after 3 months,the mortality rate in this study was 8.6%(9/105),of which 88.9%(8/9)were heart failure-related deaths,28.6%(30/105)of patients were readmitted,and 83.3%(25/30)of patients were readmitted due to heart failure.5.At 6 months after discharge,the utilization rates of ACEI/ARB/ARNI,beta-blockers and MRA were 69.0%,78.6%and 78.6%,respectively.The utilization rate of ACEI/ARB/ARNI,β-blocker and MRA was 56.0%.At follow-up after 6 months,10.2%(9/88)of the patients realized that their symptoms were improving and stopped taking medication;1(1.1%)of the patients stopped taking medication after discharge due to the difficulty in purchasing drugs due to the remote location;3.4%(3/88)of the patients reduced the drug dose by themselves;Other major factors affecting drug therapy and drug dosage were contraindications such as hypotension,bradycardia and deterioration of renal function,as well as failure to go to hospital for reexamination.At 6 months after discharge,the mortality rate in this study was 4.5%(4/88),all of which were heart failure-related deaths,26.1%(23/88)were readmitted,and 91.3%(21/23)were readmitted due to heart failure.By the end of 6 months after discharge,a total of 17 patients died in this study,with a total mortality rate of 15.5%(17/110),among which the deaths related to heart failure accounted for 94.1%(16/17).6.In the follow-up after discharge,patients in the poor prognosis group were more likely to be complicated with diabetes and chronic kidney disease than patients in the good prognosis group,and the levels of BNP,sST2 and troponin were all higher(P<0.05).7.The scores of EQ-5D,EQ-VAS and MLHFQ at 3 and 6 months after discharge were all higher than those during hospitalization,and the differences were statistically significant(P<0.05),suggesting that the quality of life of patients at 3 and 6 months after discharge was improved compared with that before discharge.However,there was no significant difference between MMAS-8 scores at 3 and 6 months after discharge and those during hospitalization.[Conclusions]1.Among HFrEF patients hospitalized in our hospital,the utilization rate of ACEI/ARB/ARNI and beta-blocker were low,and the dose used was seriously insufficient,which had a big gap with the recommended dose in the guidelines.In addition,during the follow-up period,the drug utilization rate continued to decline,and the dosage did not change significantly.The current situation of HFrEF drug treatment was not ideal.2.During hospitalization,drugs contraindication or intolerance were the main reasons for not using drugs or substandard drug doses.However,after discharge,in addition to the drugs contraindication or intolerances,there were factors affecting the application of drugs,such as poor patients’ poor awareness of re-examination,the difficulty in purchasing drugs due to long distance,and the non-prescription by local doctors.3.In this study,the overall prognosis of patients with HFrEF was poor,with an in-hospital mortality rate of 3.6%and a total mortality rate of 15.5%,among which the deaths related to heart failure accounted for 94.1%.The reasons for the high in-hospital mortality and total mortality of HFrEF patients may be related to the lack of standardized drug therapy and poor awareness of follow-up.4.Elevated levels of BNP,sST2 and troponin,as well as diabetes mellitus and chronic kidney disease are associated with poor prognosis in patients with HFrEF.