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Casey MF, Hallmark J, Chang PP, Rodgers JE, Mehta A, Chari SV, Skersick P, Bohrmann T, Goyal P, Meyer ML. Emergency Department Use of Heart Failure-Exacerbating Medications in Patients with Chronic Heart Failure. Drug Saf 2024:10.1007/s40264-024-01479-5. [PMID: 39264483 DOI: 10.1007/s40264-024-01479-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND Use of heart failure-exacerbating medications (HFEMs) may lead to preventable episodes of acute decompensated heart failure (HF). HFEMs use is common in patients with HF, and there may be opportunities to reduce their use from the emergency department (ED). METHODS We performed an observational study on patients with HF presenting to EDs within a healthcare system between 1 January 2016 and 31 December 2020. Patients with chronic HF were identified using diagnostic codes within the electronic health record. The cohort was restricted to ambulatory (i.e., discharged to home) ED encounters. Medications, either ordered in the ED or prescribed at ED discharge, were extracted from the medication administration record and identified as potential HFEMs based on the 2016 American Heart Association Scientific Statement. Descriptive statistics were used to summarize the prevalence of HFEM use during ambulatory ED encounters. Exploratory analyses to identify correlates of HFEM use were performed. RESULTS The study cohort included 23,907 ED encounters. ED administration or prescription of HFEMs occurred during 20% of ambulatory ED encounters. HFEM administration in the ED (17%) was more common than HFEM prescription at ED discharge (6%). The most common HFEMs administered in the ED included nonsteroidal anti-inflammatory drugs (11%) and albuterol (7%). CONCLUSION HFEM use is common in patients with HF seeking ED care, occurring in roughly one-fifth of ambulatory ED encounters. There may be opportunities to optimize medication use among patients with HF in the ED.
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Affiliation(s)
- Martin F Casey
- Department of Emergency Medicine, University of North Carolina School of Medicine, 170 Manning Dr, CB# 7594, Chapel Hill, NC, 27599-7594, USA.
| | - Joy Hallmark
- Department of Emergency Medicine, University of North Carolina School of Medicine, 170 Manning Dr, CB# 7594, Chapel Hill, NC, 27599-7594, USA
| | - Patricia P Chang
- Division of Cardiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jo E Rodgers
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Aakash Mehta
- Department of Emergency Medicine, University of North Carolina School of Medicine, 170 Manning Dr, CB# 7594, Chapel Hill, NC, 27599-7594, USA
| | - Srihari V Chari
- Department of Emergency Medicine, University of North Carolina School of Medicine, 170 Manning Dr, CB# 7594, Chapel Hill, NC, 27599-7594, USA
| | - Preston Skersick
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | | | - Parag Goyal
- Division of Cardiology, Weill Cornell Medicine, New York, NY, USA
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Michelle L Meyer
- Department of Emergency Medicine, University of North Carolina School of Medicine, 170 Manning Dr, CB# 7594, Chapel Hill, NC, 27599-7594, USA
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Uemura Y, Shibata R, Sawada K, Ishikawa S, Takemoto K, Murohara T, Watarai M. Prognostic impact of polypharmacy and discharge medications in octogenarians and nonagenarian patients with acute heart failure. Heart Vessels 2024; 39:514-523. [PMID: 38386100 DOI: 10.1007/s00380-024-02366-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/18/2024] [Indexed: 02/23/2024]
Abstract
With the increasing frequency of heart failure (HF) in elderly patients, polypharmacy has become a major concern owing to its adverse outcomes. However, reports on the clinical impact of polypharmacy and discharge medications in hospitalized super-aged patients with acute HF are rare. Data from 682 patients aged 80 years or older, hospitalized for treating acute HF, were analyzed. We recorded the number of medications at discharge and classified them into three groups: HF, non-HF cardiovascular, and non-cardiovascular medications. We investigated the correlation of polypharmacy, defined as daily administration of 10 or more medications at discharge, and the use of discharge medications with post-discharge prognosis. Polypharmacy was recorded in 24.3% of enrolled patients. Polypharmacy was not an independent predictor of all-cause mortality, the incidence of cardiac-related death, or HF-associated rehospitalization; however, the number of non-cardiovascular medications, multiple usage of potentially inappropriate medications, use of mineralocorticoid receptor antagonists, and doses of loop diuretics were associated with poor prognosis. Polypharmacy was significantly associated with higher mortality in patients with Barthel index ≥ 60 at discharge; hence, physical function at discharge was useful for the stratification of prognostic impacts of polypharmacy. The current study demonstrated that polypharmacy was not essentially associated with poor prognosis in super-aged patients with acute HF. Appropriate medications that consider the patient's physical function, rather than polypharmacy itself, are important for the management of HF.
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Affiliation(s)
- Yusuke Uemura
- Cardiovascular Center, Anjo Kosei Hospital, 28 Higashi-Hirokute, Anjo, 446-8602, Japan.
| | - Rei Shibata
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Shinji Ishikawa
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenji Takemoto
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Watarai
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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3
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Goyal P, Didomenico RJ, Pressler SJ, Ibeh C, White-Williams C, Allen LA, Gorodeski EZ. Cognitive Impairment in Heart Failure: A Heart Failure Society of America Scientific Statement. J Card Fail 2024; 30:488-504. [PMID: 38485295 DOI: 10.1016/j.cardfail.2024.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 03/19/2024]
Abstract
Cognitive impairment is common among adults with heart failure (HF), as both diseases are strongly related to advancing age and multimorbidity (including both cardiovascular and noncardiovascular conditions). Moreover, HF itself can contribute to alterations in the brain. Cognition is critical for a myriad of self-care activities that are necessary to manage HF, and it also has a major impact on prognosis; consequently, cognitive impairment has important implications for self-care, medication management, function and independence, and life expectancy. Attuned clinicians caring for patients with HF can identify clinical clues present at medical encounters that suggest cognitive impairment. When present, screening tests such as the Mini-Cog, and consideration of referral for comprehensive neurocognitive testing may be indicated. Management of cognitive impairment should focus on treatment of underlying causes of and contributors to cognitive impairment, medication management/optimization, and accommodation of deficiencies in self-care. Given its implications on care, it is important to integrate cognitive impairment into clinical decision making. Although gaps in knowledge and challenges to implementation exist, this scientific statement is intended to guide clinicians in caring for and meeting the needs of an increasingly complex and growing subpopulation of patients with HF.
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Affiliation(s)
- Parag Goyal
- Program for the Care and Study of the Aging Heart, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Robert J Didomenico
- University of Illinois Chicago College of Pharmacy, Department of Pharmacy Practice, Chicago, IL
| | | | - Chinwe Ibeh
- Columbia University Irving Medical Center, New York, NY
| | | | - Larry A Allen
- University of Colorado School of Medicine, Aurora, CO
| | - Eiran Z Gorodeski
- University Hospitals, Harrington Heart & Vascular Institute, and Case Western Reserve University School of Medicine, Cleveland, OH.
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4
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Kanai M, Minamisawa M, Motoki H, Seko Y, Kimura K, Okano T, Ueki Y, Yoshie K, Kato T, Saigusa T, Ebisawa S, Okada A, Ozasa N, Kato T, Kuwahara K. Prognostic Impact of Hyperpolypharmacy Due to Noncardiovascular Medications in Patients After Acute Decompensated Heart Failure - Insights From the Clue of Risk Stratification in the Elderly Patients With Heart Failure (CURE-HF) Registry. Circ J 2023; 88:33-42. [PMID: 37544741 DOI: 10.1253/circj.cj-22-0712] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND Hyperpolypharmacy is associated with adverse outcomes in older adults, but because literature on its association with cardiovascular (CV) outcomes after acute decompensated heart failure (ADHF) is sparse, we investigated the relationships among hyperpolypharmacy, medication class, and death in patients with HF. METHODS AND RESULTS We evaluated the total number of medications prescribed to 884 patients at discharge following ADHF. Patients were categorized into nonpolypharmacy (<5 medications), polypharmacy (5-9 medications), and hyperpolypharmacy (≥10 medications) groups. We examined the relationship of polypharmacy status with the 2-year mortality rate. The proportion of patients taking ≥5 medications was 91.3% (polypharmacy, 55.3%; hyperpolypharmacy, 36.0%). Patients in the hyperpolypharmacy group showed worse outcomes than patients in the other 2 groups (P=0.002). After multivariable adjustment, the total number of medications was significantly associated with an increased risk of death (hazard ratio [HR] per additional increase in the number of medications, 1.05; 95% confidence interval [CI], 1.01-1.10; P=0.027). Although the number of non-CV medications was significantly associated with death (HR, 1.07; 95% CI, 1.02-1.13; P=0.01), the number of CV medications was not (HR, 1.01; 95% CI, 0.92-1.10; P=0.95). CONCLUSIONS Hyperpolypharmacy due to non-CV medications was associated with an elevated risk of death in patients after ADHF, suggesting the importance of a regular review of the prescribed drugs including non-CV medications.
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Affiliation(s)
- Masafumi Kanai
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | | | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Yuta Seko
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Kazuhiro Kimura
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Takahiro Okano
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Yasushi Ueki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Koji Yoshie
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Tamon Kato
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Tatsuya Saigusa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Soichiro Ebisawa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Ayako Okada
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Neiko Ozasa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
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5
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Liu E, Nahid M, Musse M, Chen L, Hilmer SN, Zullo A, Kwak MJ, Lachs M, Levitan EB, Safford MM, Goyal P. Prescribing patterns of fall risk-increasing drugs in older adults hospitalized for heart failure. BMC Cardiovasc Disord 2023; 23:372. [PMID: 37495948 PMCID: PMC10373421 DOI: 10.1186/s12872-023-03401-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/15/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Older adults hospitalized for heart failure (HF) are at risk for falls after discharge. One modifiable contributor to falls is fall risk-increasing drugs (FRIDs). However, the prevalence of FRIDs among older adults hospitalized for HF is unknown. We describe patterns of FRIDs use and examine predictors of a high FRID burden. METHODS We used the national biracial REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a prospective cohort recruited from 2003-2007. We included REGARDS participants aged ≥ 65 years discharged alive after a HF hospitalization from 2003-2017. We determined FRIDs -cardiovascular (CV) and non-cardiovascular (non-CV) medications - at admission and discharge from chart abstraction of HF hospitalizations. We examined the predictors of a high FRID burden at discharge via modified Poisson regression with robust standard errors. RESULTS Among 1147 participants (46.5% women, mean age 77.6 years) hospitalized at 676 hospitals, 94% were taking at least 1 FRID at admission and 99% were prescribed at least 1 FRID at discharge. The prevalence of CV FRIDs was 92% at admission and 98% at discharge, and the prevalence of non-CV FRIDs was 32% at admission and discharge. The most common CV FRID at admission (88%) and discharge (93%) were antihypertensives; the most common agents were beta blockers (61% at admission, 75% at discharge), angiotensin-converting enzyme inhibitors (36% vs. 42%), and calcium channel blockers (32% vs. 28%). Loop diuretics had the greatest change in prevalence (53% vs. 72%). More than half of the cohort (54%) had a high FRID burden (Agency for Healthcare Research and Quality (AHRQ) score ≥ 6), indicating high falls risk after discharge. In a multivariable Poisson regression analysis, the factors strongly associated with a high FRID burden at discharge included hypertension (PR: 1.41, 95% CI: 1.20, 1.65), mood disorder (PR: 1.24, 95% CI: 1.10, 1.38), and hyperpolypharmacy (PR: 1.88, 95% CI: 1.64, 2.14). CONCLUSIONS FRID use was nearly universal among older adults hospitalized for HF; more than half had a high FRID burden at discharge. Further work is needed to guide the management of a common clinical conundrum whereby guideline indications for treating HF may contribute to an increased risk for falls.
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Affiliation(s)
- Esther Liu
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA
| | - Musarrat Nahid
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA
| | - Mahad Musse
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA
| | - Ligong Chen
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sarah N Hilmer
- The University of Sydney and Royal North Shore Hospital, Sydney, NSW, Australia
| | - Andrew Zullo
- Brown University School of Public Health, Providence, USA
| | | | - Mark Lachs
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA
| | | | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA.
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Goyal P, Kwak MJ, Al Malouf C, Kumar M, Rohant N, Damluji AA, Denfeld QE, Bircher KK, Krishnaswami A, Alexander KP, Forman DE, Rich MW, Wenger NK, Kirkpatrick JN, Fleg JL. Geriatric Cardiology: Coming of Age. JACC. ADVANCES 2022; 1:100070. [PMID: 37705890 PMCID: PMC10498100 DOI: 10.1016/j.jacadv.2022.100070] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 09/15/2023]
Abstract
Older adults with cardiovascular disease (CVD) contend with deficits across multiple domains of health due to age-related physiological changes and the impact of CVD. Multimorbidity, polypharmacy, cognitive changes, and diminished functional capacity, along with changes in the social environment, result in complexity that makes provision of CVD care to older adults challenging. In this review, we first describe the history of geriatric cardiology, an orientation that acknowledges the unique needs of older adults with CVD. Then, we introduce 5 essential principles for meeting the needs of older adults with CVD: 1) recognize and consider the potential impact of multicomplexity; 2) evaluate and integrate constructs of cognition into decision-making; 3) evaluate and integrate physical function into decision-making; 4) incorporate social environmental factors into management decisions; and 5) elicit patient priorities and health goals and align with care plan. Finally, we review future steps to maximize care provision to this growing population.
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Affiliation(s)
- Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Min Ji Kwak
- Division of Geriatric and Palliative Medicine, McGovern Medical School, Houston, Texas, USA
| | - Christina Al Malouf
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Manish Kumar
- Department of Internal Medicine, Pat and Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Namit Rohant
- Division of Cardiology, University of Arizona, Tucson, Arizona, USA
| | - Abdulla A. Damluji
- Division of Cardiology, Inova Center of Outcomes Research, Falls Church, Virginia, USA
| | - Quin E. Denfeld
- School of Nursing and Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Kim K. Bircher
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Ashok Krishnaswami
- Section of Geriatric Medicine, Division of Primary Care and Population Health, Stanford University, Stanford, California, USA
- Geriatric Research Education and Clinical Center (GRECC), U.S. Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California, USA
- Division of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, California, USA
| | - Karen P. Alexander
- Department of Medicine/Cardiology, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Daniel E. Forman
- Divisions of Geriatrics and Cardiology, Department of Medicine, University of Pittsburgh, and VA Pittsburgh GRECC, Pittsburgh, Pennsylvania, USA
| | - Michael W. Rich
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Nanette K. Wenger
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - James N. Kirkpatrick
- Division of Cardiology and Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jerome L. Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
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Use of potentially inappropriate medications for heart failure according to the three sets of heart failure-specific criteria in Thai older patients with heart failure. J Geriatr Cardiol 2022; 19:498-510. [PMID: 35975013 PMCID: PMC9361164 DOI: 10.11909/j.issn.1671-5411.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To study the prevalence of potentially inappropriate medications for patients with heart failure (PIMHF) use and to identify factors associated with PIMHF use in Thai older HF patients. METHODS This cross-sectional analytical survey included data on older (≥ 60 years) HF patients obtained from the electronic medical record databases of secondary- and tertiary-care hospitals. The medication profiles of patients were assessed to examine whether they were prescribed any PIMHF after an HF diagnosis. For PIMHF detection, the HF-specific criteria, including 2014 St Vincent criteria, 2019 Beers criteria, and 2021 Thailand criteria were applied. The prevalence of PIMHF use was expressed as percentages. The associated factors were identified using a binary logistic regression analysis, expressed as the adjusted odds ratio (aOR) and 95% confidence interval (95% CI). RESULTS A total of 2,639 patients were included in the study. Thirty-two PIMHF were found to have been prescribed to these patients. The prevalence of PIMHF use identified by the ST Vincent criteria, the Beers criteria, the Thailand criteria, and the three combined criteria was 23.76%, 19.67%, 21.18%, and 25.16%, respectively. The factors associated with PIMHF use were secondary-care hospital (aOR = 1.54, 95% CI: 1.26-1.87), HF with preserved ejection fraction (HFpEF) (aOR = 1.81, 95% CI: 1.38-2.38), hypertension (HTN) (aOR = 1.24, 95% CI: 1.02-1.51), diabetes mellitus (DM) (aOR = 1.39, 95% CI: 1.10-1.75), chronic pulmonary diseases (CPD) (aOR = 2.09, 95% CI: 1.56-2.80), and connective tissue diseases (CTD) (aOR = 5.10, 95% CI: 2.20-11.83). CONCLUSIONS PIMHF are commonly used in Thai older HF patients. The factors associated with PIMHF use identified in this study include secondary-care hospital, HFpEF, HTN, DM, CPD, and CTD.
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