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Patterson SJ, Reaves AB, Tolley EA, Ulrich D, Hilty C, Clarke CJ, Self TH. Underutilization of Aldosterone Antagonists in Heart Failure. Hosp Pharm 2017; 52:698-703. [PMID: 29276242 DOI: 10.1177/0018578717724886] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Treatment with an aldosterone antagonist (AA) has been shown in multiple trials to reduce heart failure (HF)-related morbidity, mortality, and hospital readmission. American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) treatment guidelines recommend the use of an AA in all HF patients with an ejection fraction ≤35% and no known contraindication. Several studies have documented underuse of AA. Objectives: To determine the proportion of patients who received AA therapy consistent with the ACCF/AHA guidelines. Secondary objectives included determining the proportion of patients who received an AA inconsistent with guidelines and 30- and 90-day readmission rates. Methods: A retrospective chart review was conducted of patients admitted to an inner city academic medical center with a diagnosis of HF between August 16, 2011, and June 5, 2013. Results: A total of 346 HF admissions (87.6% African American) were evaluated. Use of an AA at discharge was consistent with guidelines in 31% of patients. A total of 121 patients (35%) were discharged on an AA. Among the remaining 225 patients who were not discharged on an AA, 170 (75.6%) had no contraindication to therapy. Sixty-one patients were readmitted within 30 days, and a total of 108 patients were readmitted within 90 days. There were no significant differences in readmission rates between patients who were discharged on AA therapy and those who were not. Conclusion: AAs are still underutilized in the treatment of HF.
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Affiliation(s)
| | - Anne B Reaves
- Methodist University Hospital, USA.,The University of Tennessee Health Science Center, Memphis, USA
| | | | | | | | - Catherine J Clarke
- Methodist University Hospital, USA.,The University of Tennessee Health Science Center, Memphis, USA
| | - Timothy H Self
- The University of Tennessee Health Science Center, Memphis, USA
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52
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Cooper LB, Lippmann SJ, Greiner MA, Sharma A, Kelly JP, Fonarow GC, Yancy CW, Heidenreich PA, Hernandez AF. Use of Mineralocorticoid Receptor Antagonists in Patients With Heart Failure and Comorbid Diabetes Mellitus or Chronic Kidney Disease. J Am Heart Assoc 2017; 6:e006540. [PMID: 29275368 PMCID: PMC5779000 DOI: 10.1161/jaha.117.006540] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 10/26/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Perceived risks of hyperkalemia and acute renal insufficiency may limit use of mineralocorticoid receptor antagonist (MRA) therapy in patients with heart failure, especially those with diabetes mellitus or chronic kidney disease. METHODS AND RESULTS Using clinical registry data linked to Medicare claims, we analyzed patients hospitalized with heart failure between 2005 and 2013 with a history of diabetes mellitus or chronic kidney disease. We stratified patients by MRA use at discharge. We used inverse probability-weighted proportional hazards models to assess associations between MRA therapy and 30-day, 1-year, and 3-year mortality, all-cause readmission, and readmission for heart failure, hyperkalemia, and acute renal insufficiency. We performed interaction analyses for differential effects on 3-year outcomes for reduced, borderline, and preserved ejection fraction. Of 16 848 patients, 12.3% received MRA therapy at discharge. Higher serum creatinine was associated with lower odds of MRA use (odds ratio, 0.66; 95% confidence interval, 0.61-0.71); serum potassium was not (odds ratio, 1.00; 95% confidence interval, 0.90-1.11). There was no mortality difference between groups. MRA therapy was associated with greater risks of readmission for hyperkalemia and acute renal insufficiency and lower risks of long-term all-cause readmission. Patients on MRA therapy with borderline or preserved ejection fraction had greater risks of readmission for hyperkalemia (P=0.02) and acute renal insufficiency (P<0.001); patients with reduced ejection fraction did not. CONCLUSIONS Among patients with heart failure and diabetes mellitus or chronic kidney disease, MRA use was associated with lower risk of all-cause readmission despite greater risk of hyperkalemia and acute renal insufficiency.
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Affiliation(s)
- Lauren B Cooper
- Heart Failure and Transplant Program, Inova Heart & Vascular Institute, Inova Fairfax Hospital, Falls Church, VA
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Steven J Lippmann
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Melissa A Greiner
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Abhinav Sharma
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Jacob P Kelly
- Department of Medicine, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, Los Angeles, CA
| | - Clyde W Yancy
- Department of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | - Adrian F Hernandez
- Department of Medicine, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Pergola PE, Spiegel DM, Warren S, Yuan J, Weir MR. Patiromer Lowers Serum Potassium When Taken without Food: Comparison to Dosing with Food from an Open-Label, Randomized, Parallel Group Hyperkalemia Study. Am J Nephrol 2017; 46:323-332. [PMID: 29017162 PMCID: PMC5804834 DOI: 10.1159/000481270] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 08/30/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patiromer is a sodium-free, nonabsorbed, potassium binder approved for treatment of hyperkalemia. This open-label study compares the efficacy and safety of patiromer administered without food versus with food. METHODS Adults with hyperkalemia (potassium ≥5.0 mEq/L) were randomized (1:1) to receive patiromer once daily without food or with food for 4 weeks. The dosage was adjusted (maximum: 25.2 g/day) using a prespecified titration schedule to achieve and maintain potassium within a target range (3.8-5.0 mEq/L). The primary efficacy endpoint was the proportion of patients with serum potassium in the target range at either week 3 or week 4. Safety was assessed by adverse events (AEs) and laboratory testing. RESULTS Efficacy was evaluated in 112 patients; 65.2% were ≥65 years of age, 75.9% had chronic kidney disease, and 82.1% had diabetes. Baseline mean serum potassium was similar in the without-food (5.44 mEq/L) and with-food (5.34 mEq/L) groups. The primary endpoint was achieved by 87.3% (95% CI 75.5-94.7) and 82.5% (95% CI 70.1-91.3) of patients in the with-food and without-food groups, respectively; least squares mean changes in serum potassium from baseline to week 4 were -0.65 and -0.62 mEq/L, respectively (p < 0.0001). The most common AEs were diarrhea and constipation. Serum K+ remained ≥3.5 mEq/L in all patients; 5 patients developed serum magnesium <1.4 mg/dL, including 4 whose baseline magnesium was below the lower limit of normal. CONCLUSION Patiromer is equally effective and well tolerated when taken without food or with food, thereby offering the potential for dosing flexibility.
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Affiliation(s)
| | - David M. Spiegel
- Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, California, USA
| | - Suzette Warren
- Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, California, USA
| | - Jinwei Yuan
- Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, California, USA
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54
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Krueger K, Griese-Mammen N, Schubert I, Kieble M, Botermann L, Laufs U, Kloft C, Schulz M. In search of a standard when analyzing medication adherence in patients with heart failure using claims data: a systematic review. Heart Fail Rev 2017; 23:63-71. [DOI: 10.1007/s10741-017-9656-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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55
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Ferreira JP, Rossignol P, Machu JL, Sharma A, Girerd N, Anker SD, Cleland JG, Dickstein K, Filippatos G, Hillege HL, Lang CC, Ter Maaten JM, Metra M, Ng L, Ponikowski P, Samani NJ, van Veldhuisen DJ, Zwinderman AH, Voors A, Zannad F. Mineralocorticoid receptor antagonist pattern of use in heart failure with reduced ejection fraction: findings from BIOSTAT-CHF. Eur J Heart Fail 2017; 19:1284-1293. [PMID: 28580625 DOI: 10.1002/ejhf.900] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/25/2017] [Accepted: 05/05/2017] [Indexed: 12/26/2022] Open
Abstract
AIMS Mineralocorticoid receptor antagonists (MRAs) are recommended (unless contraindicated) to all patients with heart failure with reduced ejection fraction (HFrEF). However, MRAs are still largely underused in routine clinical practice. This study aims to describe the determinants and pattern of use of MRAs in HFrEF. METHODS AND RESULTS BIOSTAT-CHF is a European multicentre, prospective study which enrolled patients suboptimally treated with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARBs) and/or beta-blockers, with the aim of optimizing guideline-based use of these agents. From the original 2516 subjects, this retrospective post hoc analysis included the 1325 patients with an indication for MRA therapy (i.e. left ventricular ejection fraction ≤35%, estimated glomerular filtration rate ≥30 mL/min/1.73 m2 , K+ ≤5.0 mmol/L). The mean age was 66.1 ± 12.2 years. At baseline an MRA was prescribed to 741 (56%) patients. Patients who were prescribed MRAs at baseline were younger, more often male, had higher body mass index, lower sodium, higher proportion of hypertension history and ACEi/ARB prescription (all P < 0.05). Of the 1049 patients who completed the baseline plus the 9 month visit, 585 (56%) had an MRA prescribed at baseline and 662 (63%) had an MRA prescribed at 9 months. Among the 585 patients with MRA at baseline, 91 (16%) had discontinued therapy and among the 461 (44%) patients without MRA at baseline 168 (36%) had initiated therapy subsequently. MRA discontinuation was more likely in subjects with higher left ventricular ejection fraction and NYHA class III/IV (P < 0.05 for both). MRA prescription both at baseline and 9 months was not associated with the outcome of death or heart failure hospitalization (adjusted hazard ratio 1.02, 95% confidence interval 0.66-1.58; P = 0.93). CONCLUSIONS In this prospective observational study across Europe, MRAs were largely under-prescribed and frequently discontinued. Owing to these dynamic changes, outcome inferences are inconclusive.
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Affiliation(s)
- João Pedro Ferreira
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France.,Cardiovascular Research and Development Unit, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Jean-Loup Machu
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Abhinav Sharma
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Nicolas Girerd
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Stefan D Anker
- Department of Innovative Clinical Trials, University Medical Centre Göttingen (UMG), Robert-Koch-Straße, D-37075, Göttingen, Germany
| | - John G Cleland
- Robertson Centre for Biostatistics and Glasgow Clinical Trials Unit, Glasgow, UK
| | - Kenneth Dickstein
- University of Bergen, Bergen, Norway.,Stavanger University Hospital, Stavanger, Norway
| | - Gerasimos Filippatos
- National and Kopodistrian University of Athens, School of Medicine, Heart Failure Unit, Department of Cardiology, Athens University Hospital Attikon, Rimini 1, Athens, 12462, Greece
| | - Hans L Hillege
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands.,Program of Applied Translational Research, Yale University, New Haven, CT, USA
| | | | - Leong Ng
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK and NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - Piotr Ponikowski
- Department of Cardiology, Centre for Heart Diseases, 4th Military Hospital, Wroclaw, Poland and Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Nilesh J Samani
- Department of Cardiovascular Sciences, University of Leicester, BHF Cardiovascular Research Centre, Glenfield Hospital, Groby Rd, Leicester, LE3 9QP, UK
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - Aeilko H Zwinderman
- Academic Medical Center, Clinical Epidemiology Biostatistics and Bioinformatics, Amsterdam, The Netherlands
| | - Adriaan Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
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56
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Steinberg BA, Piccini JP. Arrhythmias in 2016: Arrhythmia treatment - evidence catching up with technology. Nat Rev Cardiol 2017; 14:75-76. [PMID: 28094273 DOI: 10.1038/nrcardio.2016.219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, 50 North Medical Drive, Salt Lake City, Utah 84132, USA
| | - Jonathan P Piccini
- Division of Cardiology, Duke University Medical Center and the Duke Clinical Research Institute, 2400 Pratt Street, Durham, North Carolina 27705, USA
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57
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Cooper LB, Hammill BG, Peterson ED, Pitt B, Maciejewski ML, Curtis LH, Hernandez AF. Characterization of Mineralocorticoid Receptor Antagonist Therapy Initiation in High-Risk Patients With Heart Failure. Circ Cardiovasc Qual Outcomes 2017; 10:e002946. [PMID: 28073850 PMCID: PMC5228387 DOI: 10.1161/circoutcomes.116.002946] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 10/21/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Heart failure guidelines recommend routine monitoring of serum potassium, and renal function in patients treated with a mineralocorticoid receptor antagonist (MRA). How these recommendations are implemented in high-risk patients or according to setting of drug initiation is poorly characterized. METHODS AND RESULTS We conducted a retrospective cohort study of Medicare beneficiaries linked to laboratory data in 10 states with prevalent heart failure as of July 1, 2011, and incident MRA use between May 1 and September 30, 2011. Outcomes included laboratory testing before MRA initiation and in the early (days 1-10) and extended (days 11-90) post-initiation periods, based on setting of drug initiation and the presence of renal insufficiency. Additional outcomes included abnormal laboratory results and adverse events proximate to MRA initiation. Of 10 443 Medicare beneficiaries with heart failure started on an MRA, 19.7% were initiated during a hospitalization. Appropriate follow-up laboratory testing across all time periods occurred in 25.2% of patients with inpatient initiation compared with 2.8% of patients begun as an outpatient. Patients with chronic kidney disease had higher rates of both hyperkalemia and acute kidney failure in the early (1.3% and 2.7%, respectively) and extended (5.6% and 9.8%, respectively) post-initiation periods compared with those without chronic kidney disease. CONCLUSIONS Patients initiated on MRA therapy as an outpatient had extremely poor rates of guideline indicated follow-up laboratory monitoring after drug initiation. In particular, patients with chronic kidney disease are at high risk for adverse events after MRA initiation. Quality improvement initiatives focused on systems to improve appropriate laboratory monitoring are needed.
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Affiliation(s)
- Lauren B Cooper
- From the Inova Heart and Vascular Institute, Falls Church, VA (L.B.C.); Department of Medicine (L.B.C., E.D.P., M.L.M., L.H.C., A.F.H.) and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (B.G.H., E.D.P., L.H.C., A.F.H.); Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC (M.L.M.).
| | - Bradley G Hammill
- From the Inova Heart and Vascular Institute, Falls Church, VA (L.B.C.); Department of Medicine (L.B.C., E.D.P., M.L.M., L.H.C., A.F.H.) and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (B.G.H., E.D.P., L.H.C., A.F.H.); Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC (M.L.M.)
| | - Eric D Peterson
- From the Inova Heart and Vascular Institute, Falls Church, VA (L.B.C.); Department of Medicine (L.B.C., E.D.P., M.L.M., L.H.C., A.F.H.) and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (B.G.H., E.D.P., L.H.C., A.F.H.); Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC (M.L.M.)
| | - Bertram Pitt
- From the Inova Heart and Vascular Institute, Falls Church, VA (L.B.C.); Department of Medicine (L.B.C., E.D.P., M.L.M., L.H.C., A.F.H.) and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (B.G.H., E.D.P., L.H.C., A.F.H.); Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC (M.L.M.)
| | - Matthew L Maciejewski
- From the Inova Heart and Vascular Institute, Falls Church, VA (L.B.C.); Department of Medicine (L.B.C., E.D.P., M.L.M., L.H.C., A.F.H.) and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (B.G.H., E.D.P., L.H.C., A.F.H.); Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC (M.L.M.)
| | - Lesley H Curtis
- From the Inova Heart and Vascular Institute, Falls Church, VA (L.B.C.); Department of Medicine (L.B.C., E.D.P., M.L.M., L.H.C., A.F.H.) and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (B.G.H., E.D.P., L.H.C., A.F.H.); Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC (M.L.M.)
| | - Adrian F Hernandez
- From the Inova Heart and Vascular Institute, Falls Church, VA (L.B.C.); Department of Medicine (L.B.C., E.D.P., M.L.M., L.H.C., A.F.H.) and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (B.G.H., E.D.P., L.H.C., A.F.H.); Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.); and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC (M.L.M.)
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Lack of evidence of lower 30-day all-cause readmission in Medicare beneficiaries with heart failure and reduced ejection fraction discharged on spironolactone. Int J Cardiol 2016; 227:462-466. [PMID: 27866868 DOI: 10.1016/j.ijcard.2016.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/28/2016] [Accepted: 11/02/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Therapy with evidence-based heart failure (HF) medications has been shown to be associated with lower risk of 30-day all-cause readmission in patients with HF and reduced ejection fraction (HFrEF). METHODS We examined the association of aldosterone antagonist use with 30-day all-cause readmission in this population. Of the 2443 Medicare beneficiaries with HF and left ventricular EF ≤35% discharged home from 106 Alabama hospitals during 1998-2001, 2060 were eligible for spironolactone therapy (serum creatinine ≤2.5 for men and ≤2mg/dl for women, and serum potassium <5mEq/L). After excluding 186 patients already receiving spironolactone on admission, the inception cohort consisted of 1874 patients eligible for a new discharge prescription for spironolactone, of which 329 received one. Using propensity scores for initiation of spironolactone therapy, we assembled a matched cohort of 324 pairs of patients receiving and not receiving spironolactone balanced on 34 baseline characteristics (mean age 72years, 42% women, 33% African American). RESULTS Thirty-day all-cause readmission occurred in 17% and 19% of matched patients receiving and not receiving spironolactone, respectively (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.64-1.32; p=0.650). Spironolactone had no association with 30-day all-cause mortality (HR, 0.84; 95% CI, 0.38-1.88; p=0.678) or HF readmission (HR, 0.74; 95% CI, 0.41 1.31; p=0.301). These associations remained unchanged during 12months of post-discharge follow-up. CONCLUSION A discharge prescription for spironolactone had no association with 30-day all-cause readmission among older, hospitalized Medicare beneficiaries with HFrEF eligible for spironolactone therapy.
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Dev S, Hoffman TK, Kavalieratos D, Heidenreich P, Wu WC, Schwenke DC, Tracy SJ. Barriers to Adoption of Mineralocorticoid Receptor Antagonists in Patients With Heart Failure: A Mixed-Methods Study. J Am Heart Assoc 2016; 5:e002493. [PMID: 27032719 PMCID: PMC4943238 DOI: 10.1161/jaha.115.002493] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 02/09/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Mineralocorticoid receptor antagonists (MRAs) are the most underutilized pharmacotherapy for heart failure. Minimal data are available on the barriers to MRA adoption from the perspective of prescribing clinicians. METHODS AND RESULTS A mixed-methods study consisting of a survey (n=50), focus groups (n=39), interviews (n=6) with clinicians at a single US Department of Veterans Affairs medical center served to ascertain barriers to optimal use of MRAs. Participants were drawn from 6 groups: cardiology providers, cardiology fellows, hospitalists, clinical pharmacists, internal medicine residents, and primary care providers. Qualitative data were iteratively coded with qualitative data analysis software. The survey response rate was 17.3%. Overall, 51% of survey respondents were unfamiliar with eplerenone, and 6% were unfamiliar with spironolactone. In addition, 30% of respondents reported that they would order a laboratory test >2 weeks after a new MRA prescription, although that is beyond the guideline recommendation. Most providers correctly identified New York Heart Association class 3 and 4 patients as MRA eligible, but only 42% identified class 2 patients as MRA eligible. Through analysis of focus groups, we identified 8 barriers to MRA use in 3 categories: patient-based barriers (concerns about polypharmacy and comorbidities, adverse effects, perceived patient nonadherence), provider-based barriers (unclear roles and responsibilities, coordination and transitions of care, lack of experience or familiarity with MRAs), and system-based barriers (system overload and provider time constraints, lack of systematic follow-up procedures). CONCLUSIONS Eight primary barriers to MRA adoption at the provider, patient, and health system levels were identified from the prescriber perspective. These barriers can inform the creation of multilevel interventions that will be required to close the gap in MRA adoption.
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Affiliation(s)
- Sandesh Dev
- Cardiology Section, Phoenix VA Health Care System, Phoenix, AZ
| | - Trisha K Hoffman
- Hugh Downs School of Human Communication, Arizona State University, Tempe, AZ
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
| | | | - Wen-Chih Wu
- Cardiology Section, Providence VA Medical Center, Providence, RI
| | - Dawn C Schwenke
- Research Section, Phoenix VA Health Care System, Phoenix, AZ
| | - Sarah J Tracy
- Hugh Downs School of Human Communication, Arizona State University, Tempe, AZ
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60
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DeVore AD, Mi X, Mentz RJ, Fonarow GC, Van Dyke MK, Maya JF, Hardy NC, Hammill BG, Hernandez AF. Discharge heart rate and β-blocker dose in patients hospitalized with heart failure: Findings from the OPTIMIZE-HF registry. Am Heart J 2016; 173:172-8. [PMID: 26920611 DOI: 10.1016/j.ahj.2015.10.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 10/29/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Elevated heart rate of ≥70 beats/min despite β-blocker use may represent a new treatment target in patients in sinus rhythm with heart failure with reduced ejection fraction. However, little is known about the proportion of patients with elevated heart rate despite β-blocker therapy. METHODS We analyzed data from a large clinical registry to describe discharge heart rate as a function of β-blocker use and dose. We included patients with left ventricular ejection fraction <40% who were admitted with acute heart failure in 2003 and 2004; we excluded patients with a history of atrial arrhythmia or with a pacemaker or cardiac resynchronization therapy. We considered the β-blockers carvedilol, metoprolol succinate, bisoprolol, atenolol, and metoprolol tartrate and described discharge dose as a percentage of target dose (ie, <25%, 25%-49%, 50%-99%, and ≥100%). RESULTS Among 10,696 patients, median discharge heart rate was 76 beats/min (interquartile range [IQR] 66-86 beats/min). Of these, 7,826 (73%) were discharged on a β-blocker. For patients not on a β-blocker, median discharge heart rate was 80 beats/min (IQR 70-89 beats/min), compared with 78 beats/min (IQR 69-88 beats/min) on <25% of target dose, 75 beats/min (IQR 66-85 beats/min) on 25% to 49% of target dose, 74 beats/min (IQR 66-82 beats/min) on 50% to 99% of target dose, and 72 beats/min (IQR 65% to 80%) on 100% of target dose or greater (P < .001). Most patients, 7,647 (71%), had a discharge heart rate of ≥70 beats/min, including 1,460 (63%) of 2,301 patients discharged on 50% of target dose or greater. CONCLUSIONS Despite treatment with β-blockers, a substantial proportion of patients hospitalized with heart failure with reduced ejection fraction have elevated heart rate at discharge.
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Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC.
| | - Xiaojuan Mi
- Duke Clinical Research Institute, Durham, NC
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, CA
| | | | | | | | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
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Sisyphus and 30-Day Heart Failure Readmissions. JACC-HEART FAILURE 2016; 4:21-3. [DOI: 10.1016/j.jchf.2015.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 10/12/2015] [Indexed: 11/17/2022]
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Dev S, Lacy ME, Masoudi FA, Wu W. Temporal Trends and Hospital Variation in Mineralocorticoid Receptor Antagonist Use in Veterans Discharged With Heart Failure. J Am Heart Assoc 2015; 4:e002268. [PMID: 26702082 PMCID: PMC4845296 DOI: 10.1161/jaha.115.002268] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 10/21/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite concerns about mineralocorticoid receptor antagonist therapies (MRAs) underuse and misuse in patients with heart failure, temporal and institutional variations of MRA prescription have not been reported. METHODS AND RESULTS We studied a national sample of veterans hospitalized for heart failure between 2003 and 2009 and left ventricular ejection fraction <40%. We identified ideal and non-ideal candidates for MRA therapy based on American College of Cardiology/American Heart Association guidelines. We measured temporal trends and hospital variation of MRA prescriptions within 90 days after discharge. We determined the median odds ratio (MOR), a measure of the relative odds of an MRA prescription for 2 individuals with similar characteristics discharged at 2 randomly selected hospitals. From 37 126 patients (n=131 hospitals), 9355 were ideal-MRA candidates, and 4056 were non-ideal candidates. Among ideal candidates, 36% received an MRA, but there was a decline in use (41% in 2003 to 31% in 2009, P<0.001). Of non-ideal candidates, 27% received an MRA with a decline in use (34% in 2003 to 22% in 2009, P<0.001). Hospital MRA prescription ranged from 0% to 71% for ideal candidates and 0% to 100% for non-ideal candidates. The median odds ratios of MRA prescription for ideal and non-ideal candidates were 1.44 and 1.36, respectively; a median odds ratio >1.2 indicates significant practice-level variation. CONCLUSIONS There was decreasing MRA use between 2003 and 2009 with wide institutional variation in MRA prescription, which suggests opportunities for improvement to stimulate MRA use in ideal candidates while further reducing use in those with contraindications.
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Affiliation(s)
| | - Mary E. Lacy
- Brown UniversityProvidenceRI
- Providence VA Medical CenterProvidenceRI
| | | | - Wen‐Chih Wu
- Brown UniversityProvidenceRI
- Providence VA Medical CenterProvidenceRI
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Role of the acute care nurse in managing patients with heart failure using evidence-based care. Crit Care Nurs Q 2015; 37:357-76. [PMID: 25185764 DOI: 10.1097/cnq.0000000000000036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Acute heart failure is a major US public health problem, accounting for more than 1 million hospitalizations each year. As part of the health care team, nurses play an important role in the evaluation and management of patients presenting to the emergency department with acute decompensated heart failure. Once acute decompensation is controlled, nurses also play a critical role in preparing patients for hospital discharge and educating patients and caregivers about strategies to improve long-term outcomes and prevent future decompensation and rehospitalization. Nurses' assessment skills and comprehensive knowledge of acute and chronic heart failure are important to optimize patient care and improve outcomes from initial emergency department presentation through discharge and follow-up. This review presents an overview of current heart failure guidelines, with the goal of providing acute care cardiac nurses with information that will allow them to better use their knowledge of heart failure to facilitate diagnosis, management, and education of patients with acute heart failure.
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Brown K, Chee J, Kyung S, Vettichira B, Papadimitriou L, Butler J. Mineralocorticoid Receptor Antagonism in Acute Heart Failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015. [PMID: 26199117 DOI: 10.1007/s11936-015-0402-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OPINION STATEMENT Heart failure (HF) remains a tremendous burden to health care systems and patients worldwide. The cornerstone neurohormonal disruption that leads to the debilitating sequelae in HF patients revolves primarily around aldosterone and the renin-angiotensin-aldosterone system (RAAS). Aldosterone plays a detrimental role in tissue remodeling by inducing inflammation and fibrosis within the cardiovascular and renal systems, leaving mineralocorticoid receptor antagonists (MRAs) as key pharmacological tools to slow pathogenesis and improve patient outcomes. The role of MRA in improving morbidity and mortality in outpatients with chronic HF and low ejection fraction is well established and supported by large randomized controlled trials. However, evidence-based data relating to the use of MRA in acute HF (AHF) remain somewhat limited, and therefore, the use of MRA is not ubiquitously considered in the acute setting. Current studies for the use of MRA in AHF are limited by small sample size as well as safety concerns relating to the dose-dependent effects on electrolyte homeostasis and renal function. Here, we discuss the imperative need for additional trials elucidating the potential benefits of MRA in AHF as an adjunct diuretic therapy. We not only discuss the role of MRA in neurohormonal regulation of aldosterone but also highlight a potential dose-dependent role for MRA in natriuresis. Furthermore, we showcase existing and recent evidence-based data demonstrating the effectiveness of MRA in AHF and on long-term outcomes. Finally, we look at several treatment strategies and safety concerns as they relate to MRA use so as to aid in avoidance of MRA-related complications while facilitating achievement of treatment goals.
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Affiliation(s)
- Kemar Brown
- Division of Cardiology, Health Sciences Center, Stony Brook University, T-16, Room 080, Stony Brook, NY, 11794, USA
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Bhatia V, Bajaj NS, Sanam K, Hashim T, Morgan CJ, Prabhu SD, Fonarow GC, Deedwania P, Butler J, Carson P, Love TE, Kheirbek R, Aronow WS, Anker SD, Waagstein F, Fletcher R, Allman RM, Ahmed A. Beta-blocker Use and 30-day All-cause Readmission in Medicare Beneficiaries with Systolic Heart Failure. Am J Med 2015; 128:715-21. [PMID: 25554369 PMCID: PMC6756434 DOI: 10.1016/j.amjmed.2014.11.036] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 10/23/2014] [Accepted: 11/22/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Beta-blockers improve outcomes in patients with systolic heart failure. However, it is unknown whether their initial negative inotropic effect may increase 30-day all-cause readmission, a target outcome for Medicare cost reduction and financial penalty for hospitals under the Affordable Care Act. METHODS Of the 3067 Medicare beneficiaries discharged alive from 106 Alabama hospitals (1998-2001) with a primary discharge diagnosis of heart failure and ejection fraction <45%, 2202 were not previously on beta-blocker therapy, of which 383 received new discharge prescriptions for beta-blockers. Propensity scores for beta-blocker use, estimated for each of the 2202 patients, were used to assemble a matched cohort of 380 pairs of patients receiving and not receiving beta-blockers who were balanced on 36 baseline characteristics (mean age 73 years, mean ejection fraction 27%, 45% women, 33% African American). RESULTS Beta-blocker use was not associated with 30-day all-cause readmission (hazard ratio [HR] 0.87; 95% confidence interval [CI], 0.64-1.18) or heart failure readmission (HR 0.95; 95% CI, 0.57-1.58), but was significantly associated with lower 30-day all-cause mortality (HR 0.29; 95% CI, 0.12-0.73). During 4-year postdischarge, those in the beta-blocker group had lower mortality (HR 0.81; 95% CI, 0.67-0.98) and combined outcome of all-cause mortality or all-cause readmission (HR 0.87; 95% CI, 0.74-0.97), but not with all-cause readmission (HR 0.89; 95% CI, 0.76-1.04). CONCLUSIONS Among hospitalized older patients with systolic heart failure, discharge prescription of beta-blockers was associated with lower 30-day all-cause mortality and 4-year combined death or readmission outcomes without higher 30-day readmission.
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Affiliation(s)
- Vikas Bhatia
- University of Alabama at Birmingham, Birmingham, Ala; Veterans Affairs Medical Center, Birmingham, Ala.
| | - Navkaranbir S Bajaj
- University of Alabama at Birmingham, Birmingham, Ala; Veterans Affairs Medical Center, Birmingham, Ala
| | - Kumar Sanam
- University of Alabama at Birmingham, Birmingham, Ala
| | | | | | - Sumanth D Prabhu
- University of Alabama at Birmingham, Birmingham, Ala; Veterans Affairs Medical Center, Birmingham, Ala
| | | | | | | | | | | | | | | | - Stefan D Anker
- Department of Innovative Clinical Trials, University Medical Centre Göttingen, Göttingen, Germany
| | | | | | - Richard M Allman
- Department of Veterans Affairs, Geriatrics and Extended Care Services, Washington, DC
| | - Ali Ahmed
- Veterans Affairs Medical Center, Washington, DC
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Girerd N, Collier T, Pocock S, Krum H, McMurray JJ, Swedberg K, Van Veldhuisen DJ, Vincent J, Pitt B, Zannad F. Clinical benefits of eplerenone in patients with systolic heart failure and mild symptoms when initiated shortly after hospital discharge: analysis from the EMPHASIS-HF trial. Eur Heart J 2015; 36:2310-7. [PMID: 26093641 DOI: 10.1093/eurheartj/ehv273] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 05/27/2015] [Indexed: 12/25/2022] Open
Abstract
AIMS Cardiovascular hospitalization (CVH) in patients with heart failure (HF) is associated with a high post-discharge rate of early re-admission and CV death. Eplerenone might be effective in reducing the incidence of these adverse clinical outcomes during this period. METHODS AND RESULTS The EMPHASIS-HF trial compared eplerenone with placebo added to standard therapy in 2737 patients with New York Heart Association class II HF and left ventricular ejection fraction ≤35%. We conducted a post hoc analysis in the 2338 patients randomized within 180 days of a CVH. The interaction between the time from the qualifying CVH to randomization and the primary outcome of CV death or hospitalization for HF (HHF), as well as other secondary outcomes, was assessed in Cox survival models. Most of the qualifying CVHs were HHF (N = 1496, 64.0%), acute coronary syndromes (N = 390, 16.7%), and arrhythmias (N = 197, 7.2%). The median time of study drug initiation from qualifying CVH was 42 days. The relative rate reductions in CV death/HHF, HHF, and all-cause mortality were similar (P for interaction = 0.65, 0.44, and 0.40, respectively) whether the treatment was initiated <42 or 42+ days after qualifying CVH. Absolute rate reductions were -5.61 [-8.67, -2.55] events per 100 patient × years in the <42 days group and -3.58 [-6.37, -0.79] in the 42+ days group. The adverse effects of eplerenone were also unaffected by the time from the qualifying CVH. CONCLUSION Eplerenone is safe, improves survival, and may prevent re-admission when initiated soon after a hospitalization for HF or acute coronary syndromes in patients with systolic HF and mild symptoms.
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Affiliation(s)
- Nicolas Girerd
- INSERM, Centre D'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, 4 Rue du Morvan, 54500 Vandoeuvre lès Nancy, France
| | - Tim Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Henry Krum
- Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - John J McMurray
- The British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden National Heart and Lung Institute, Imperial College, London, UK
| | - Dirk J Van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Bertram Pitt
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Faiez Zannad
- INSERM, Centre D'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, 4 Rue du Morvan, 54500 Vandoeuvre lès Nancy, France
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Oh J, Kang SM, Song MK, Hong N, Youn JC, Han S, Jeon ES, Cho MC, Kim JJ, Yoo BS, Chae SC, Oh BH, Choi DJ, Lee MM, Ryu KH. Clinical benefit of spironolactone in patients with acute decompensated heart failure and severe renal dysfunction: Data from the Korean Heart Failure Registry. Am Heart J 2015; 169:713-720.e3. [PMID: 25965719 DOI: 10.1016/j.ahj.2015.01.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 01/17/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUNDS We investigated the relationship between spironolactone use and all-cause mortality in acute decompensated heart failure (ADHF) patients with severe renal dysfunction. The clinical benefit of spironolactone in the treatment of heart failure (HF) has been described in several large randomized clinical trials. However, its clinical benefits have not been studied in hospitalized ADHF patients with severe renal dysfunction (estimated glomerular filtration rate [eGFR] <45 mL/min per 1.73 m(2)). METHODS AND RESULTS We retrospectively analyzed data from the Korean Heart Failure Registry. We included 1,035 ADHF patients with severe renal dysfunction. In Kaplan-Meier survival analysis, all-cause mortality in the spironolactone-treated group was significantly lower than that in the nonspironolactone group (18.1% vs 24.9%, respectively, log rank P = .028). However, spironolactone use was not an independent predictor after adjusting other HF risk factors (hazard ratio 0.974, 95% CI 0.681-1.392, P = .884) and after propensity score matching (P = .115). In subgroup analysis, the clinical benefit of spironolactone use was preserved in women, prehospital spironolactone use, the chronic kidney disease stage 3b (eGFR 30-44 mL/min per 1.73 m(2)), and the appropriate spironolactone use (eGFR ≥30 mL/min per 1.73 m(2) and K ≤5.0 mmol/L). CONCLUSION The spironolactone therapy was not beneficial in ADHF patients with severe renal dysfunction after multivariable adjusting and propensity score matching. However, we reassured the current HF guidelines for spironolactone use and the clinical benefit in chronic kidney disease stage 3b should be assessed in future clinical trial.
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Affiliation(s)
- Jaewon Oh
- Cardiology Division, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seok-Min Kang
- Cardiology Division, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Mi Kyung Song
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Namki Hong
- Cardiology Division, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong-Chan Youn
- Cardiology Division, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seongwoo Han
- Cardiology Division, Hallym University Medical Center, Hwaseong, Korea
| | - Eun-Seok Jeon
- Cardiology Division, Sungkyunkwan University Samsung Medical Center, Seoul, Republic of Korea
| | - Myeong-Chan Cho
- Cardiology Division, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Jae-Joong Kim
- Cardiology Division, Ulsan University Asan Medical Center, Seoul, Republic of Korea
| | - Byung-Su Yoo
- Cardiology Division, Yonsei University Wonju Christian Hospital, Wonju, Republic of Korea
| | - Shung Chull Chae
- Cardiology Division, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Byung-Hee Oh
- Cardiology Division, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong-Ju Choi
- Cardiology Division, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Myung-Mook Lee
- Cardiology Division, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Kyu-Hyung Ryu
- Cardiology Division, Hallym University Medical Center, Hwaseong, Korea
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Patel K, Fonarow GC, Ahmed M, Morgan C, Kilgore M, Love TE, Deedwania P, Aronow WS, Anker SD, Ahmed A. Calcium channel blockers and outcomes in older patients with heart failure and preserved ejection fraction. Circ Heart Fail 2014; 7:945-52. [PMID: 25296862 DOI: 10.1161/circheartfailure.114.001301] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Little is known about associations of calcium channel blockers (CCBs) with outcomes in patients with heart failure and preserved ejection fraction (EF). METHODS AND RESULTS Of the 10 570 hospitalized patients with heart failure and preserved EF, ≥65 years, EF ≥40%, in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF; 2003-2004), linked to Medicare data (through December 31, 2008), 7514 had no prior history of CCB use. Of these, 815 (11%) patients received new discharge prescriptions for CCBs. Propensity scores for CCB initiation, calculated for each of the 7514 patients, were used to assemble a matched cohort of 1620 (810 pairs) patients (mean age, 80 years; mean EF, 56%; 65% women; 10% black) receiving and not receiving CCBs, balanced on 114 baseline characteristics. The primary composite end point of all-cause mortality or heart failure hospitalization occurred in 82% and 81% of patients receiving and not receiving CCBs (hazard ratio for CCBs, 1.03; 95% confidence interval, 0.92-1.14). Hazard ratios (95% confidence intervals) for all-cause mortality, heart failure hospitalization, and all-cause hospitalization were 1.05 (0.94-1.18), 1.05 (0.91-1.21), and 1.03 (0.93-1.14), respectively. Similar associations were observed when we categorized patients into those receiving amlodipine and nonamlodipine CCBs. Among 7514 prematch patients, multivariable-adjusted and propensity-adjusted hazard ratios (95% confidence interval) for primary composite end point were 1.03 (0.95-1.12) and 1.02 (0.94-1.11), respectively. CONCLUSIONS In hospitalized older patients with heart failure, new discharge prescriptions for CCBs had no associations with composite or individual end points of mortality or heart failure hospitalization, regardless of the class of CCBs.
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Affiliation(s)
- Kanan Patel
- From the Department of Medicine, University of California, San Francisco (K.P.); Division of Cardiology, University of California, Los Angeles (G.C.F.); Comprehensive Center for Healthy Aging (M.A.), Department of Biostatistics (C.M.) and Department of Health Care Organization and Policy (M.K.), School of Public Health, University of Alabama at Birmingham (M.A., C.M., M.K.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, University of California, San Francisco, Fresno (P.D.); Department of Medicine, New York Medical College, Valhalla, NY (W.S.A.); Department of Innovative Clinical Trials, University Medical Centre Göttingen, Göttingen, Germany (S.D.A.); Center for Health and Aging, Veterans Affairs Medical Center, Washington, DC (A.A.)
| | - Gregg C Fonarow
- From the Department of Medicine, University of California, San Francisco (K.P.); Division of Cardiology, University of California, Los Angeles (G.C.F.); Comprehensive Center for Healthy Aging (M.A.), Department of Biostatistics (C.M.) and Department of Health Care Organization and Policy (M.K.), School of Public Health, University of Alabama at Birmingham (M.A., C.M., M.K.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, University of California, San Francisco, Fresno (P.D.); Department of Medicine, New York Medical College, Valhalla, NY (W.S.A.); Department of Innovative Clinical Trials, University Medical Centre Göttingen, Göttingen, Germany (S.D.A.); Center for Health and Aging, Veterans Affairs Medical Center, Washington, DC (A.A.)
| | - Momanna Ahmed
- From the Department of Medicine, University of California, San Francisco (K.P.); Division of Cardiology, University of California, Los Angeles (G.C.F.); Comprehensive Center for Healthy Aging (M.A.), Department of Biostatistics (C.M.) and Department of Health Care Organization and Policy (M.K.), School of Public Health, University of Alabama at Birmingham (M.A., C.M., M.K.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, University of California, San Francisco, Fresno (P.D.); Department of Medicine, New York Medical College, Valhalla, NY (W.S.A.); Department of Innovative Clinical Trials, University Medical Centre Göttingen, Göttingen, Germany (S.D.A.); Center for Health and Aging, Veterans Affairs Medical Center, Washington, DC (A.A.)
| | - Charity Morgan
- From the Department of Medicine, University of California, San Francisco (K.P.); Division of Cardiology, University of California, Los Angeles (G.C.F.); Comprehensive Center for Healthy Aging (M.A.), Department of Biostatistics (C.M.) and Department of Health Care Organization and Policy (M.K.), School of Public Health, University of Alabama at Birmingham (M.A., C.M., M.K.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, University of California, San Francisco, Fresno (P.D.); Department of Medicine, New York Medical College, Valhalla, NY (W.S.A.); Department of Innovative Clinical Trials, University Medical Centre Göttingen, Göttingen, Germany (S.D.A.); Center for Health and Aging, Veterans Affairs Medical Center, Washington, DC (A.A.)
| | - Meredith Kilgore
- From the Department of Medicine, University of California, San Francisco (K.P.); Division of Cardiology, University of California, Los Angeles (G.C.F.); Comprehensive Center for Healthy Aging (M.A.), Department of Biostatistics (C.M.) and Department of Health Care Organization and Policy (M.K.), School of Public Health, University of Alabama at Birmingham (M.A., C.M., M.K.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, University of California, San Francisco, Fresno (P.D.); Department of Medicine, New York Medical College, Valhalla, NY (W.S.A.); Department of Innovative Clinical Trials, University Medical Centre Göttingen, Göttingen, Germany (S.D.A.); Center for Health and Aging, Veterans Affairs Medical Center, Washington, DC (A.A.)
| | - Thomas E Love
- From the Department of Medicine, University of California, San Francisco (K.P.); Division of Cardiology, University of California, Los Angeles (G.C.F.); Comprehensive Center for Healthy Aging (M.A.), Department of Biostatistics (C.M.) and Department of Health Care Organization and Policy (M.K.), School of Public Health, University of Alabama at Birmingham (M.A., C.M., M.K.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, University of California, San Francisco, Fresno (P.D.); Department of Medicine, New York Medical College, Valhalla, NY (W.S.A.); Department of Innovative Clinical Trials, University Medical Centre Göttingen, Göttingen, Germany (S.D.A.); Center for Health and Aging, Veterans Affairs Medical Center, Washington, DC (A.A.)
| | - Prakash Deedwania
- From the Department of Medicine, University of California, San Francisco (K.P.); Division of Cardiology, University of California, Los Angeles (G.C.F.); Comprehensive Center for Healthy Aging (M.A.), Department of Biostatistics (C.M.) and Department of Health Care Organization and Policy (M.K.), School of Public Health, University of Alabama at Birmingham (M.A., C.M., M.K.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, University of California, San Francisco, Fresno (P.D.); Department of Medicine, New York Medical College, Valhalla, NY (W.S.A.); Department of Innovative Clinical Trials, University Medical Centre Göttingen, Göttingen, Germany (S.D.A.); Center for Health and Aging, Veterans Affairs Medical Center, Washington, DC (A.A.)
| | - Wilbert S Aronow
- From the Department of Medicine, University of California, San Francisco (K.P.); Division of Cardiology, University of California, Los Angeles (G.C.F.); Comprehensive Center for Healthy Aging (M.A.), Department of Biostatistics (C.M.) and Department of Health Care Organization and Policy (M.K.), School of Public Health, University of Alabama at Birmingham (M.A., C.M., M.K.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, University of California, San Francisco, Fresno (P.D.); Department of Medicine, New York Medical College, Valhalla, NY (W.S.A.); Department of Innovative Clinical Trials, University Medical Centre Göttingen, Göttingen, Germany (S.D.A.); Center for Health and Aging, Veterans Affairs Medical Center, Washington, DC (A.A.)
| | - Stefan D Anker
- From the Department of Medicine, University of California, San Francisco (K.P.); Division of Cardiology, University of California, Los Angeles (G.C.F.); Comprehensive Center for Healthy Aging (M.A.), Department of Biostatistics (C.M.) and Department of Health Care Organization and Policy (M.K.), School of Public Health, University of Alabama at Birmingham (M.A., C.M., M.K.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, University of California, San Francisco, Fresno (P.D.); Department of Medicine, New York Medical College, Valhalla, NY (W.S.A.); Department of Innovative Clinical Trials, University Medical Centre Göttingen, Göttingen, Germany (S.D.A.); Center for Health and Aging, Veterans Affairs Medical Center, Washington, DC (A.A.)
| | - Ali Ahmed
- From the Department of Medicine, University of California, San Francisco (K.P.); Division of Cardiology, University of California, Los Angeles (G.C.F.); Comprehensive Center for Healthy Aging (M.A.), Department of Biostatistics (C.M.) and Department of Health Care Organization and Policy (M.K.), School of Public Health, University of Alabama at Birmingham (M.A., C.M., M.K.); Department of Medicine, Case Western Reserve University, Cleveland, OH (T.E.L.); Department of Medicine, University of California, San Francisco, Fresno (P.D.); Department of Medicine, New York Medical College, Valhalla, NY (W.S.A.); Department of Innovative Clinical Trials, University Medical Centre Göttingen, Göttingen, Germany (S.D.A.); Center for Health and Aging, Veterans Affairs Medical Center, Washington, DC (A.A.).
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Ahmed A, Bourge RC, Fonarow GC, Patel K, Morgan CJ, Fleg JL, Aban IB, Love TE, Yancy CW, Deedwania P, van Veldhuisen DJ, Filippatos GS, Anker SD, Allman RM. Digoxin use and lower 30-day all-cause readmission for Medicare beneficiaries hospitalized for heart failure. Am J Med 2014; 127:61-70. [PMID: 24257326 PMCID: PMC3929967 DOI: 10.1016/j.amjmed.2013.08.027] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 08/07/2013] [Accepted: 08/07/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Heart failure is the leading cause for hospital readmission, the reduction of which is a priority under the Affordable Care Act. Digoxin reduces 30-day all-cause hospital admission in chronic systolic heart failure. Whether digoxin is effective in reducing readmission after hospitalization for acute decompensation remains unknown. METHODS Of the 5153 Medicare beneficiaries hospitalized for acute heart failure and not receiving digoxin, 1054 (20%) received new discharge prescriptions for digoxin. Propensity scores for digoxin use, estimated for each of the 5153 patients, were used to assemble a matched cohort of 1842 (921 pairs) patients (mean age, 76 years; 56% women; 25% African American) receiving and not receiving digoxin, who were balanced on 55 baseline characteristics. RESULTS Thirty-day all-cause readmission occurred in 17% and 22% of matched patients receiving and not receiving digoxin, respectively (hazard ratio [HR] for digoxin, 0.77; 95% confidence interval [CI], 0.63-0.95). This beneficial association was observed only in those with ejection fraction <45% (HR 0.63; 95% CI, 0.47-0.83), but not in those with ejection fraction ≥ 45% (HR 0.91; 95% CI, 0.60-1.37; P for interaction, .145), a difference that persisted throughout the first 12 months postdischarge (P for interaction, .019). HRs (95% CIs) for 12-month heart failure readmission and all-cause mortality were 0.72 (0.61-0.86) and 0.83 (0.70-0.98), respectively. CONCLUSIONS In Medicare beneficiaries with systolic heart failure, a discharge prescription of digoxin was associated with lower 30-day all-cause hospital readmission, which was maintained at 12 months, and was not at the expense of higher mortality. Future randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- Ali Ahmed
- University of Alabama at Birmingham, Birmingham, Ala; Veterans Affairs Medical Center, Birmingham, Ala.
| | | | | | - Kanan Patel
- University of Alabama at Birmingham, Birmingham, Ala
| | | | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, Bethesda, Md
| | | | | | | | | | | | | | - Stefan D Anker
- Applied Cachexia Research, Charité, Campus Virchow-Klinikum, Berlin, Germany
| | - Richard M Allman
- University of Alabama at Birmingham, Birmingham, Ala; Veterans Affairs Medical Center, Birmingham, Ala
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70
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Allen LA, Shetterly S, Peterson PN, Gurwitz JH, Smith DH, Brand DW, Fairclough DL, Rumsfeld JS, Masoudi FA, Magid DJ. Guideline concordance of testing for hyperkalemia and kidney dysfunction during initiation of mineralocorticoid receptor antagonist therapy in patients with heart failure. Circ Heart Fail 2014; 7:43-50. [PMID: 24281136 PMCID: PMC3924889 DOI: 10.1161/circheartfailure.113.000709] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 11/12/2013] [Indexed: 01/06/2023]
Abstract
BACKGROUND Mineralocorticoid receptor antagonists (MRA) reduce morbidity and mortality in heart failure with reduced ejection fraction but can cause hyperkalemia and acute kidney injury. Guidelines recommend measurement of serum potassium (K) and creatinine (Cr) before and serially after MRA initiation, but the extent to which this occurs is unknown. METHODS AND RESULTS Using electronic data from 3 health systems 2005 to 2008, we performed a retrospective review of laboratory monitoring among 490 patients hospitalized for heart failure with reduced ejection fraction who were subsequently initiated on MRA therapy. Median age at time of MRA initiation was 73 years, and 37.1% were women. Spironolactone accounted for 99.4% of MRA use. Initial ambulatory MRA dispensing occurred at hospital discharge in 70.0% of cases. In the 30 days before MRA initiation, 94.3% of patients had a K or Cr measurement. Preinitiation K was >5.0 mmol/L in 1.4% and Cr>2.5 mg/dL in 1.7%. In the 7 days after MRA initiation among patients who remained alive and out of the hospital, 46.5% had no evidence of K measurement; by 30 days, 13.6% remained untested. Patient factors explained a small portion of postinitiation K testing (c-statistic, 0.67). CONCLUSIONS Although laboratory monitoring before MRA initiation for heart failure with reduced ejection fraction is common, laboratory monitoring after MRA initiation frequently does not meet guideline recommendations, even in patients at higher risk for complications. Quality improvement efforts that encourage the use of MRA should also include mechanisms to address recommended monitoring.
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Affiliation(s)
- Larry A. Allen
- Colorado Cardiovascular Outcomes Research Consortium, Denver, CO
- University of Colorado School of Medicine, Aurora, CO
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Susan Shetterly
- Colorado Cardiovascular Outcomes Research Consortium, Denver, CO
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Pamela N. Peterson
- Colorado Cardiovascular Outcomes Research Consortium, Denver, CO
- University of Colorado School of Medicine, Aurora, CO
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
- Denver Health Medical Center, Denver, CO
| | - Jerry H. Gurwitz
- Meyers Primary Care Institute and Fallon Community Health Plan, Worcester, MA
| | - David H. Smith
- Kaiser Permanente Center for Health Research, Portland, OR
| | - David W. Brand
- Colorado Cardiovascular Outcomes Research Consortium, Denver, CO
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | | | - John S. Rumsfeld
- Colorado Cardiovascular Outcomes Research Consortium, Denver, CO
- University of Colorado School of Medicine, Aurora, CO
- Veterans Administration Medical Center, Denver, CO
| | - Frederick A. Masoudi
- Colorado Cardiovascular Outcomes Research Consortium, Denver, CO
- University of Colorado School of Medicine, Aurora, CO
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - David J. Magid
- Colorado Cardiovascular Outcomes Research Consortium, Denver, CO
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
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71
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Eapen ZJ, Hammill BG, Setoguchi S, Schulman KA, Peterson ED, Hernandez AF, Curtis LH. Who enrolls in the Medicare Part D prescription drug benefit program? Medication use among patients with heart failure. J Am Heart Assoc 2013; 2:e000242. [PMID: 24025363 PMCID: PMC3835226 DOI: 10.1161/jaha.113.000242] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background Dispensing data from Medicare Part D standalone prescription drug plans are now available, but characteristics of enrollees with heart failure have not been well described. Methods and Results We identified 81 874 patients with prevalent heart failure as of January 1, 2010, in a nationally representative 5% sample of Medicare beneficiaries. We classified patients according to enrollment in a Medicare Part D plan as of January 1, 2010. Demographic characteristics, comorbid conditions, and prescriptions were compared by enrollment status. A total of 49 252 (60.2%) were enrolled in a Medicare Part D plan as of January 1. Enrollees were more often women, black, and of lower socioeconomic status. Enrollees with heart failure more often filled prescriptions for loop diuretics than angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, β‐blockers, or aldosterone antagonists. During the first 4 months of 2010, 5444 (12.3%) reached the coverage gap, and 566 (1.3%) required catastrophic coverage beyond the gap. Conclusions Medicare beneficiaries with heart failure differ significantly according to enrollment in Part D prescription drug plans and represent a population underrepresented in clinical efficacy trials. Many face the coverage gap, and few select Medicare Part D plans that provide coverage during the gap. Linking Medicare Part D event data with clinical registries could help to determine whether eligible enrollees are undertreated for heart failure.
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Affiliation(s)
- Zubin J Eapen
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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