心不全の予後評価について
アメリカ心臓病学会誌Circulationから興味深い報告がありました。心不全増悪による外来での治療介入自体が、心不全入院と同様に予後不良因子であるという報告です。 心不全患者の観察研究を行い、心不全増悪による外来での治療介入群（Ｏ群）、救急外来受診群（Ｅ群）、心不全再入院群（Ｈ群）の３群に分けています。8399人の心不全患者のうち4.3%が心不全増悪により外来での治療介入が必要となり、1.0%が救急外来受診、そして13.2%が心不全再入院。その後の死亡リスクを検討したところ、いずれの３群も同様の予後不良因子となりました（Ｏ群：ハザード比4.8、Ｅ群：ハザード比4.5、Ｈ群：ハザード比5.9）。心不全患者の予後評価として、心不全再入院だけでなく、外来での治療介入や救急外来受診も考慮にいれる必要がある、という報告です。
この観察研究の結果からも、心不全の増悪による医療機関受診をいかに起こさないようにするかが、心不全患者の生活の質を維持するために必要なことであり、多様性のある心不全増悪の予防を行うことが大切となります。
Outpatient intensification of HF therapy was added to an expanded composite outcome with ED visits, HF hospitalizations, and cardiovascular deaths. In an examination of first nonfatal events, 361 of 8399 patients (4.3%) had outpatient intensification of HF therapy without a subsequent event (ie, ED visit/HF hospitalizations) within 30 days; 78 of 8399 (1.0%) had an ED visit without previous outpatient intensification of HF therapy or a subsequent event within 30 days; and 1107 of 8399 (13.2%) had HF hospitalizations without a preceding event. The risk of death (in comparison with no-event patients) was similar after each manifestation of worsening: outpatient intensification of HF therapy (hazard ratio, 4.8; 95% confidence interval, 3.9-5.9); ED visit (hazard ratio, 4.5; 95% confidence interval, 3.0-6.7); HF hospitalizations (hazard ratio, 5.9; 95% confidence interval, 5.2-6.6). The expanded composite added 14% more events and shortened time to accrual of a fixed number of events. The benefit of sacubitril/valsartan over enalapril was similar to the primary outcome for the expanded composite (hazard ratio, 0.79; 95% confidence interval, 0.73-0.86) and was consistent across the components of the latter. Focusing only on HF hospitalizations underestimates the frequency of worsening and the serious implications of all manifestations of worsening. For clinical trials conducted in an era of heightened efforts to avoid HF hospitalizations, inclusion of episodes of outpatient treatment intensification (and ED visits) in a composite outcome adds an important number of events and shortens the time taken to accrue a target number of end points in an event-driven trial.
参考文献：Okumura N and PARADIGM-HF Investigators and Committees. Importance of Clinical Worsening of Heart Failure Treated in the Outpatient Setting. Circulation. 2016;133:2254-62
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