左心室收縮性心臟衰竭病患病因及處方型態之回溯性研究

The Retrospective Study of Etiologies and Prescribing Patterns of Patients with Left Ventricular Dysfunction

童宥慈(Yu-Tzu Tung)

指導教授 ： 黃瑞仁 ； 何藴芳

國立臺灣大學/醫學院/臨床藥學研究所/碩士(2006年)

https://doi.org/10.6342/NTU.2006.02802

摘要

雖然自1980年開始，國際間陸續有慢性心臟衰竭(chronic heart failure)治療準則公布，但許多研究發現，臨床上對於在治療準則中所建議的藥品有使用不足的情況。因此，本研究採病歷檢閱的方式，以臺大醫院左心室收縮性心臟衰竭(left ventricular systolic dysfunction)病患為研究群體，收錄自民國92年8月1日至93年7月31日間其心臟超音波檢查左心室射出率≦40%的715名病患，進行病因及處方型態分析，以了解心臟衰竭病患的治療現況。
本研究結果顯示，冠狀動脈心臟病和高血壓是最常見的可能病因(59.4%、57.3%)。利尿劑是最多病患使用的藥品(74.7%)，ACEIs/ARBs的處方率為59.1%，但β-blockers的處方率只有36%；在藥品劑量方面，則不論是ACEIs/ARBs或是β-blockers，使用的劑量約只有治療準則中所建議最大劑量的六分之ㄧ到二分之ㄧ。
有許多因子會影響這些藥品的處方率，包括病患的年齡、可能病因、所併有之其他疾病、腎臟功能等，以及影響最大的是病患的診治專科別。也就是說，當病患接受心臟外科或其他科別醫師的照護時，其處方ACEIs/ARBs、β-blockers或是spironolactone的校正勝算比，比心臟內科醫師來的低許多，為0.199-0.638 (p＜0.05)。
為了要詳細找出病患無法使用這些藥品的原因，本研究將收入的病患與四個大型心臟衰竭藥品臨床試驗，包括SOLVD（enalapril）、MERIT-HF（metoprolol）、RALES（spironolactone）以及Val-HeFT（valsartan）的納入/排除條件做比較。其中，有34.3%的病患符合SOLVD，這些病患使用ACEIs/ARBs的比例為71.1%；15.9%病患符合MERIT-HF，有使用β-blockers的佔41.9%；10.1%病患符合RALES，使用spironolactone的比例為74.6%；以及23.2%符合Val-HeFT，其中使用ACEIs/ARBs有65.4%。
以上數據顯示，即使病患已符合臨床試驗的條件了，原則上應無任何理由不使用這些藥品，但僅ACEIs/ARBs(SOLVD)和spironolactone(RALES)與不符合之病患相比，處方率有明顯增加；另兩個臨床試驗則無顯著差異。因此，確實有藥品使用不足的情形。另外，本研究也試著將病歷上有記載或病患有實驗室檢驗值異常(如Scr)之未用藥原因加以分析，但仍無法得到處方率偏低之滿意的解釋。
本研究提供了目前臺大醫院對於心臟衰竭病患的處方情形，對於ACEIs/ARBs以及β-blockers的處方比例，仍有許多改善的空間，尤其是β-blockers。因此，仍然需要持續的促進醫療人員對於治療準則的認識及了解這些藥品的風險與利益平衡，對於每名病患才能做出最適合的判斷與處置，達到對於病患最佳之醫療照護。

關鍵字

心臟衰竭 ； 病因 ； 處方型態 ； 處方率

並列摘要

Since 1980, a number of guidelines and expert consensus documents for the management of chronic heart failure have been issued by different organizations and other related societies, however, many western studies suggested that the heart failure treatment in daily practice, showing a tendency toward underuse of recommended medications, has not been fully complied with these guidelines. In order to understand the local practice pattern, the aim of this study was to assess how patients with heart failure were managed at a medical center in Taiwan.
With an attempt to analyze the etiologies and prescribing patterns of chronic heart failure in Taiwan, we retrospectively reviewed charts of 715 patients whose echocardiograms, acquired between Auguset 2003 and July 2004, showed left ventricular systolic dysfunction (LVEF≦40%).
We found that coronary artery disease (59.4%) and hypertension (57.3%) were the most common possible etiologies. Diuretics (74.7%) were most frequently prescribed for patients. Prescription rate of ACEIs/ARBs was 59.1%, yet β-blockers were used only in 36% of patients. Daily dosages of ACEIs/ARBs and, particularly, β-blockers were below their respective recommended target doses on average.
Multiple logistic regression analysis of these heart failure prescriptions indicated that the possible etiologies, age, co-morbid factors, renal function, and especially, the physicians’ subspecialties influenced the rate of prescription for recommended medications. That is, non-cardiologists were less likely to prescribe ACEIs/ARBs, β-blockers, and spironolactone (OR=0.199-0.638, p < 0.05) for patients with left ventricular systolic dysfunction.
Four internationally renowned large placebo-controlled chronic-heart-failure trials including SOLVD, Val-HeFT, MERIT-HF, and RALES have proved ACEIs, ARBs, β-blockers, and spironolactone to be safe and effective, respectively. To further elucidate possible reasons for deviating from evidence-based life-saving pharmacotherapy, we have selected appropriate patients who also fulfilled the enrolment criteria of those randomized trials for analysis. We would like to identify, in real world, the proportion of patients eligible for evidenced-based treatment and the rate of appropriate prescription.
Our data demonstrated that patients who fulfilled enrolment criteria of the four identified trials mentioned above were more likely to be treated with ACEIs/ARBs (71.1% of SOLVD-eligible patients vs. 52.7% in SOLVD-ineligible patients, p<.0001 and 65.4% of Val-HeFT-eligible patients vs. 57.1%, p=0.0834), β-blockers (41.9% of MERIT-HF-eligible patients vs. 34.9%, p=0.1941), and spironolactone (74.6% of RALES-eligible patients vs. 31.3%, p<.0001) than trial-ineligible patients. In addition, an attempt to search for reasonable explanations of the unsatisfactory prescription rate was made by analyzing chart records and laboratory data with disappointing results.
In summary, the study offered the prescription patterns of patients with chronic heart failure at a medical center in Taiwan. However, the prescription of recommended medications including ACEIs/ARBs and, particularly, β-blockers remains low. Continued medical education of chronic heart failure treatment guidelines is still warranted to improve the dissemination and implementation current knowledge in daily practice for a better care of individual patients.

並列關鍵字

heart failure ； etiology ； prescribing pattern ； prescription rate ； ACEI ； ARB ； beta-blocker ； spironolactone

參考文獻

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