期刊
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
卷 75, 期 3, 页码 245-254出版社
ELSEVIER SCIENCE INC
DOI: 10.1016/j.jacc.2019.11.003
关键词
clinical outcomes; heart failure with preserved ejection fraction; hospitalization; sacubitril/valsartan
资金
- Novartis
- KL2/Catalyst Medical Research Investigator Training award from Harvard Catalyst (National Institutes of Health/National Center for Advancing Translational Sciences Award) [UL 1TR002541]
- Baxter Healthcare
- Boehringer Ingelheim
- Gilead
- AstraZeneca
- Alnylam
- Abbott
- Vifor International
- Brahms GmbH
- Servier
- Abbott, United Pharmaceuticals
- Janssen-Cilag Pharmaceuticals
- Novartis through the University of Leuven, Belgium
- Cardiorentis
- Johnson Johnson
- Pfizer
- Theravance
- Amgen
- Lone Star Heart, Mesoblast
- National Institutes of Health/National Heart, Lung, and Blood Institute
- Theracos
- Takeda
BACKGROUND The period shortly after hospitalization for heart failure (HF) represents a high-risk window for recurrent clinical events, including rehospitalization or death. OBJECTIVES This study sought to determine whether the efficacy and safety of sacubitril/valsartan varies in relation to the proximity to hospitalization for HF among patients with HF with preserved ejection fraction (HFpEF). METHODS In this post hoc analysis of PARAGON-HF (Prospective Comparison of ARNI [Angiotensin Receptor-Neprilysin Inhibitor] with ARB [Angiotensin Receptor Blocker] Global Outcomes in HFpEF), we assessed the risk of clinical events and response to sacubitril/valsartan in relation to time from last HF hospitalization among patients with HFpEF (>= 45%). The primary outcome was composite total HF hospitalizations and cardiovascular death, analyzed by using a semiparametric proportional rates method, stratified by geographic region. RESULTS Of 4,796 validly randomized patients in PARAGON-HF, 622 (13%) were screened during hospitalization or within 30 days of prior hospitalization, 555 (12%) within 31 to 90 days, 435 (9%) within 91 to 180 days, and 694 (14%) after 180 days; 2,490 (52%) were never previously hospitalized. Over a median follow-up of 35 months, risk of total HF hospitalizations and cardiovascular death was inversely and nonlinearly associated with timing from prior HF hospitalization (p < 0.001). There was a gradient in relative risk reduction in primary events with sacubitril/valsartan from patients hospitalized within 30 days (rate ratio: 0.73; 95% confidence interval: 0.53 to 0.99) to patients never hospitalized (rate ratio: 1.00; 95% confidence interval: 0.80 to 1.24; trend in relative risk reduction: p(interaction) = 0.15). With valsartan alone, the rate of total primary events was 26.7 (<= 30 days), 24.2 (31 to 90 days), 20.7 (91 to 180 days), 15.7 (>180 days), and 7.9 (not previously hospitalized) per 100 patient-years. Compared with valsartan, absolute risk reductions with sacubitril/valsartan were more prominent in patients enrolled early after hospitalization: 6.4% (<= 30 days), 4.6% (31 to 90 days), and 3.4% (91 to 180 days), whereas no risk reduction was observed in patients screened >180 days or who were never hospitalized (trend in absolute risk reduction: p(interaction) = 0.050). CONCLUSIONS Recent hospitalization for HFpEF identifies patients at high risk for near-term clinical progression. In the PARAGON-HF trial, the relative and absolute benefits of sacubitril/valsartan compared with valsartan in HFpEF appear to be amplified when initiated in the high-risk window after hospitalization and warrant prospective validation. (C) 2020 by the American College of Cardiology Foundation.
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