北京24家医院住院冠心病患者静息心率控制及β受体阻滞剂使用状况

Effect of pathway training on rest heart rate and the application of β-blocker in coronary heart disease patients： an open-label, multi-center, prospective study

目的 调查住院冠心病患者静息心率（Resting Heart Rate,RHR）状况、β受体阻滞剂使用状况及安全性,并探讨经“冠心病患者心率达标临床路径培训”后上述指标的变化情况.方法 采用开放、多中心的前瞻性研究,通过解放军总医院伦理委员会批准,所有研究对象均签署知情同意书.连续入选北京24家医院2012年6月至2013年2月（期间分两个时间段,各8周）的住院冠心病患者,总计3 204例（第1阶段1 570例、第2阶段1 634例）.记录并比较入、出院时患者的静息心率及β受体阻滞剂的状况.比较两阶段不良事件及严重不良事件发生情况.第1阶段不给予临床医师任何培训及干预,第2阶段开始时各中心临床医师经统一的“冠心病患者心率达标临床路径培训”大纲进行培训1周.结果 入院时患者平均静息心率为（71 ±13）次/min,出院时平均静息心率为（63±9）次/min,两阶段出院时心率达标率分别为35.9％ （564/1 570）和48.3％ （789/1 634）,差异有统计学意义（P＜0.001）;第1阶段入、出院β受体阻滞剂使用率分别为80.1％和81.0％,差异无统计学意义（P =0.162）,以琥珀酸美托洛尔为例平均剂量为（38±18）和（39 ±42） mg/d（P＜0.001）;第2阶段入、出院β受体阻滞剂使用率分别为90.3％、91.3％,差异有统计学意义（P ＜0.001）,琥珀酸美托洛尔平均剂量分别为（40±23）和（46±23） mg/d,差异有统计学意义（P＜0.001）;两阶段严重不良事件发生率差异无统计学意义.结论 北京市住院冠心病患者静息心率达标率不高,β受体阻滞剂使用剂量低,经过“冠心病患者心率达标临床路径培训”,静息心率达标率、β受体阻滞剂使用率提高,且不增加不良事件发生率.

Objective To explore the mean resting heart rate （RHR）,usage and safety status of β-blocker,and associated changes after conducting clinical pathway training on patients with coronary heart disease（CHD）.Methods We performed an open-label,multi-center prospective study.The ethical approval documents was prepared before the study.A total of 3 204 hospitalized participants with CHD were enrolled,from June 2012 to February 2013 in 24 hospitals in Beijing,and informed consent was obtained from each patients this trial was divided into two continuous stages （each stage lasted for 8 weeks）.1 570 participants were enrolled at the first stage,the clinicians used the standard method to administer β-blockers to these patients.At the second stage,β-blockers were administered to 1 634 enrolled patients by trained clinicians.The mean RHR,β-blocker usage status were recorded on the day of admission and discharge.We also described adverse events and severe adverse events.Results The average RHR at baseline and discharge were（71 ± 13）bpm and （63 ± 9）bpm.The proportion of patients reaching the RHR goals when discharged was 35.9％ in stage 1 vs 48.3％ （P ＜ 0.001） in stage 2.The rate of β-blocker usage was 80.1％ vs 81.0％ （P =0.162） in stage 1,90.3％ vs 91.3％ （P ＜0.001） in stage 2.The average dose of metoprolol succinate sustained-release tablet was （38 ± 18） vs （39 ± 42） mg/d （P ＜ 0.001） in stage 1,（40±23） vs （46±23） mg/d（P ＜0.001）in stage 2.The severe adverse events at both stages had no significant differences.Conclusion The proportion of patients with CHD reaching the RHR goals and the average dose of β-blocker was low.However,the proportion of patients reaching the RHR goals,the rate of β-blocker usage and the average dose of β-blocker were all increased after clinical pathway training.