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Bertero E, Miceli R, Lorenzoni A, Balbi M, Ghigliotti G, Chiarella F, Brunelli C, Viazzi F, Pontremoli R, Canepa M, Ameri P. Causes and impact on survival of underuse of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in heart failure. Intern Emerg Med 2019; 14:1083-1090. [PMID: 30835055 DOI: 10.1007/s11739-019-02060-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 02/21/2019] [Indexed: 12/11/2022]
Abstract
Guidelines recommend angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARB) for treatment of heart failure with reduced ejection fraction (HFrEF), but these medications are underprescribed in clinical practice. We reviewed the records of HF patients receiving a first visit in a tertiary outpatient clinic from January 1st 2004 to May 31st 2015, and selected those with a serum creatinine concentration (sCr) available at both the first and last visit and < 3.5 mg/dL at baseline, and a left ventricular ejection fraction (LVEF) < 50% at the first visit. Of 570 eligible patients, 92 (16.1%) never received ACEi/ARB. Compared to ACEi/ARB users, never-users were older, more often women, had higher sCr and lower systolic blood pressure, were less commonly on beta-blocker, and had more frequently anemia. Current or prior cancer also tended to be more common in ACEi/ARB never-users. ACEi/ARB users displayed an improvement in LVEF by ≥ 10% of the baseline value more often than ACEi/ARB never-users (33.7% vs. 20.7%, respectively, P = 0.01), whereas no difference in percent variation of sCr levels was found between the two groups (8.2% vs. 3.1%, respectively; P = 0.13). Over a median follow-up of 56 months (range 1-137 months), 215 (37.7%) patients died. After multiple adjustments, ACEi/ARB never-use was associated with an almost twofold increased risk of all-cause mortality (HR 1.97, 95%CI 1.39-2.80). ACEi/ARB underuse in HFrEF is a standing issue with dramatic prognostic consequences. Efforts are needed to eliminate perceived contraindications to these drugs and ensure their implementation in real-life cardiology.
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Affiliation(s)
- Edoardo Bertero
- Department of Internal Medicine, University of Genova, Genoa, Italy
- Comprehensive Heart Failure Center, University Clinic Würzburg, Würzburg, Germany
| | - Roberta Miceli
- Department of Internal Medicine, University of Genova, Genoa, Italy
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Alessandra Lorenzoni
- Department of Internal Medicine, University of Genova, Genoa, Italy
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Manrico Balbi
- Department of Internal Medicine, University of Genova, Genoa, Italy
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Giorgio Ghigliotti
- Department of Internal Medicine, University of Genova, Genoa, Italy
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesco Chiarella
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Claudio Brunelli
- Department of Internal Medicine, University of Genova, Genoa, Italy
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesca Viazzi
- Department of Internal Medicine, University of Genova, Genoa, Italy
- Nephrology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genova, Genoa, Italy
- Internal Medicine Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Marco Canepa
- Department of Internal Medicine, University of Genova, Genoa, Italy.
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - Pietro Ameri
- Department of Internal Medicine, University of Genova, Genoa, Italy.
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
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Xia TL, Huang FY, Li YM, Chai H, Huang BT, Ou YWX, Li Q, Pu XB, Zuo ZL, Peng Y, Chen M, Huang DJ. The impact of age on the implementation of evidence-based medications in patients with coronary artery disease and its prognostic significance: a retrospective cohort study. BMC Public Health 2018; 18:150. [PMID: 29343223 PMCID: PMC5772723 DOI: 10.1186/s12889-018-5049-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 01/09/2018] [Indexed: 02/05/2023] Open
Abstract
Background Elderly patients with coronary artery disease (CAD) frequently complicated with more cardiovascular risk factors, but received fewer evidence-based medications (EBMs). This study explored the association of EBMs compliance in different age groups and the risk of long-term death. Methods A retrospective analysis was conducted from a single registered database. 2830 consecutive patients with CAD were enrolled and grouped into 3 categories by age. The primary end point was all-cause mortality and secondary endpoint is cardiovascular mortality. Results The mean follow-up time was 30.25 ± 11.89 months and death occurred in 270 cases,including 150 cases of cardiac death. Cumulative survival curves indicated that the incidence rates of all-cause death and cardiovascular death increased with age (older than 75 years old vs. 60 to 75 years old vs. younger than 60 years old, mortality: 18.7% vs. 9.6% vs. 4.1%, p < 0.001; cardiovascular mortality: 10.3% vs. 5.1% vs. 2.7%, p < 0.001). The percentage of elderly patients using no EBMs was significantly higher than the percentages in the other age group (7.7% vs. 4.6% vs. 2.2%,p < 0.05). Cox regression analysis revealed the benefit of combination EBMs (all-cause mortality: hazard ratio [HR] 0.15, 95% CI 0.08–0.27; cardiac mortality: HR 0.08, 95% CI 0.04–0.19) for older CAD patients. Similar trends were found about different kinds of EBMs in elderly patients. Conclusions Elderly patients with CAD had higher risk of death but a lower degree of compliance with EBMs usage. Elderly CAD patients could receive more clinical benefits by using EBMs. Electronic supplementary material The online version of this article (10.1186/s12889-018-5049-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tian-Li Xia
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Chengdu, People's Republic of China
| | - Fang-Yang Huang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Chengdu, People's Republic of China
| | - Yi-Ming Li
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Chengdu, People's Republic of China
| | - Hua Chai
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Chengdu, People's Republic of China
| | - Bao-Tao Huang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Chengdu, People's Republic of China
| | - Yuan-Wei-Xiang Ou
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Chengdu, People's Republic of China
| | - Qiao Li
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Chengdu, People's Republic of China
| | - Xiao-Bo Pu
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Chengdu, People's Republic of China
| | - Zhi-Liang Zuo
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Chengdu, People's Republic of China
| | - Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Chengdu, People's Republic of China.
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Chengdu, People's Republic of China.
| | - De-Jia Huang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Chengdu, People's Republic of China
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Suwaidi JA, Asaad N, Al-Qahtani A, Al-Mulla AW, Singh R, Albinali HA. Prevalence and outcome of Middle-eastern Arab and South Asian patients hospitalized with heart failure: insight from a 20-year registry in a Middle-eastern country (1991–2010). ACTA ACUST UNITED AC 2012; 14:81-9. [DOI: 10.3109/17482941.2012.655298] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Li Q, Glynn RJ, Dreyer NA, Liu J, Mogun H, Setoguchi S. Validity of claims-based definitions of left ventricular systolic dysfunction in Medicare patients. Pharmacoepidemiol Drug Saf 2011; 20:700-8. [PMID: 21608070 DOI: 10.1002/pds.2146] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 03/09/2011] [Accepted: 03/10/2011] [Indexed: 11/11/2022]
Abstract
PURPOSE Ejection fraction (EF) is crucial information when studying the use and effectiveness of therapies in patients with heart failure (HF) and myocardial infarction (MI). We aimed to assess the validity of claims data-based definitions of systolic dysfunction (SD). METHODS We identified 1072 patients with EF recorded for an HF/MI hospitalization in Medicare linked with pharmacy data and national HF/MI registries in 1999-2006. Thirteen claims-based definitions for SD were developed using a single or combination of ICD-9 diagnosis codes and cardiovascular medications use. We calculated sensitivity, specificity, and positive predictive values (PPVs) using recorded EFs as the gold standard. RESULTS Using an EF cutoff of 45%, the definitions based on digoxin use and no atrial fibrillation or flutter had the highest PPVs (76% to 84%) and specificity (>97%) but low sensitivity (6%-14%). As we varied the EF cutoff between 50% and 25%, the specificity decreased by 3%, but the PPVs decreased by 52%. We observed potential differences in the PPVs by patients' characteristics. In a hypothetical study assessing implantable defibrillator effectiveness, using our definition to identify patients with SD would underestimate the effectiveness by 3% to 24%. In another hypothetical study comparing two classes of angiotensin system blockers where SD was considered confounding, our definition introduced ~43% misclassification bias. CONCLUSIONS Claims-based definitions for SD had excellent specificity and good PPV but low sensitivity. The definitions with good PPV could be used for cohort identification or confounding adjustment by restriction and would result in relatively small misclassification bias albeit limited generalizability.
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Affiliation(s)
- Qian Li
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
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Qian Q, Manning DM, Ou N, Klarich MJ, Leutink DJ, Loth AR, Lopez-Jimenez F. ACEi/ARB for systolic heart failure: closing the quality gap with a sustainable intervention at an academic medical center. J Hosp Med 2011; 6:156-60. [PMID: 20652962 DOI: 10.1002/jhm.803] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND National guidelines recommend angiotensin converting enzyme inhibitor (ACEi) or angiotensinogen receptor blocker (ARB) therapy for patients with left ventricular systolic dysfunction (LVSD), including those with symptomatic heart failure (HF). However, guideline adherence has not been optimal. The goal of this quality improvement project is to devise and implement a sustainable care-delivery model in a 920-bed academic hospital center that would improve ACEi/ARB adherence before hospital discharge. METHODS The Model of intervention is: (1) a computer-based daily screening program; (2) inpatient pharmacist e-flag message; and (3) alerts for inpatient care teams. Its operating algorithm: If eligible adult HF/LVSD inpatients are not on ACEi or ARB nor documentation of contraindications, a flag alert is generated; deficiency is confirmed by a pharmacist and conveyed to the patient-care teams; if alert is acted on and care brought into adherence, the screening program would not re-flag the same patients the succeeding day; if not, the patients would be re-flagged daily until reaching adherence. We compared ACEi/ARB adherence before, during, and after the intervention. RESULTS Baseline performance (percentage of eligible HF/LVSD patients receiving ACEi/ARB) was 87.5%. After implementation of the Model the ACEi/ARB adherence rate at the time of hospital discharge rose to 96.7% (P < 0.002) and was sustained for 21 months without needing additional personnel. CONCLUSIONS A carefully designed, computer-based care-delivery model is highly efficient and sustainable for enhancing ACEi/ARB adherence.
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Affiliation(s)
- Qi Qian
- Department of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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DiMartino LD, Shea AM, Hernandez AF, Curtis LH. Use of guideline-recommended therapies for heart failure in the Medicare population. Clin Cardiol 2010; 33:400-5. [PMID: 20641116 DOI: 10.1002/clc.20760] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Most information about the use of guideline-recommended therapies for heart failure reflects what occurred at discharge after an inpatient stay. HYPOTHESIS Using a nationally representative, community-dwelling sample of elderly Medicare beneficiaries, we examined how the use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and beta-blockers has changed and factors associated with their use. METHODS Using data from the Medicare Current Beneficiary Survey cost and use files matched with Medicare claims data, we identified beneficiaries for whom a diagnosis of heart failure was reported between January 1, 2000, and December 31, 2004. Data on medications prescribed during the year of cohort entry were based on patient self-report. We used multivariable logistic regression to explore relationships between the use of ACE inhibitors/ARBs and beta-blockers and patient demographic characteristics. RESULTS From 2000 through 2004, the use of ARBs increased from 12% to 19%, and the use of beta-blockers increased from 30% to 41%. The use of ACE inhibitors remained constant at 45%. Beneficiaries who reported having prescription drug insurance coverage were 32% more likely than other beneficiaries to have filled a prescription for an ACE inhibitor or ARB and 26% more likely to have filled a prescription for a beta-blocker. CONCLUSIONS Although the use of guideline-recommended therapies for heart failure has increased, it remains suboptimal.
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Affiliation(s)
- Lisa D DiMartino
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina 27715, USA
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Bueno H, Ross JS, Wang Y, Chen J, Vidán MT, Normand SLT, Curtis JP, Drye EE, Lichtman JH, Keenan PS, Kosiborod M, Krumholz HM. Trends in length of stay and short-term outcomes among Medicare patients hospitalized for heart failure, 1993-2006. JAMA 2010; 303:2141-7. [PMID: 20516414 PMCID: PMC3020983 DOI: 10.1001/jama.2010.748] [Citation(s) in RCA: 571] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
CONTEXT Whether decreases in the length of stay during the past decade for patients with heart failure (HF) may be associated with changes in outcomes is unknown. OBJECTIVE To describe the temporal changes in length of stay, discharge disposition, and short-term outcomes among older patients hospitalized for HF. DESIGN, SETTING, AND PARTICIPANTS An observational study of 6,955,461 Medicare fee-for-service hospitalizations for HF between 1993 and 2006, with a 30-day follow-up. MAIN OUTCOME MEASURES Length of hospital stay, in-patient and 30-day mortality, and 30-day readmission rates. RESULTS Between 1993 and 2006, mean length of stay decreased from 8.81 days (95% confidence interval [CI], 8.79-8.83 days) to 6.33 days (95% CI, 6.32-6.34 days). In-hospital mortality decreased from 8.5% (95% CI, 8.4%-8.6%) in 1993 to 4.3% (95% CI, 4.2%-4.4%) in 2006, whereas 30-day mortality decreased from 12.8% (95% CI, 12.8%-12.9%) to 10.7% (95% CI, 10.7%-10.8%). Discharges to home or under home care service decreased from 74.0% to 66.9% and discharges to skilled nursing facilities increased from 13.0% to 19.9%. Thirty-day readmission rates increased from 17.2% (95% CI, 17.1%-17.3%) to 20.1% (95% CI, 20.0%-20.2%; all P < .001). Consistent with the unadjusted analyses, the 2005-2006 risk-adjusted 30-day mortality risk ratio was 0.92 (95% CI, 0.91-0.93) compared with 1993-1994, and the 30-day readmission risk ratio was 1.11 (95% CI, 1.10-1.11). CONCLUSION For patients admitted with HF during the past 14 years, reductions in length of stay and in-hospital mortality, less marked reductions in 30-day mortality, and changes in discharge disposition accompanied by increases in 30-day readmission rates were observed.
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Affiliation(s)
- Héctor Bueno
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Hess G, Preblick R, Hill J, Plauschinat CA, Yaskin J. Effects of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy after hospital discharge on subsequent rehospitalization for acute myocardial infarction and heart failure. ACTA ACUST UNITED AC 2009; 15:170-5. [PMID: 19627290 DOI: 10.1111/j.1751-7133.2009.00092.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
American College of Cardiology/American Heart Association guidelines recommend angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy following acute myocardial infarction (MI) or development of heart failure (HF). This study estimated the effects of initiating these therapies after hospitalization for MI or HF on subsequent 1-year rehospitalization rates for MI or HF. A retrospective multivariate analysis of medical claims for 14,327 patients receiving and 7905 not receiving an ACEI or ARB after discharge for MI or HF was conducted. Rehospitalization for MI or HF was lower for treated vs untreated patients (MI: odds ratio [OR]=0.53, P<.001; HF: OR=0.52, P<.001). Rehospitalization was lower in treated patients with high medication compliance (medication possession ratio [MPR]>80%) and medium compliance (MPR 40%-79%) vs patients with low compliance (ORs for MI: high=0.54, medium=0.69; P<.001); ORs for HF: high=0.38, medium=0.62; P<.001). In conclusion, ACEI or ARB therapy initiated after hospitalization for MI or HF reduced risk of rehospitalization, and greater risk reduction was achieved with higher medication compliance.
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Affiliation(s)
- Gregory Hess
- Surveillance Data Inc., Germantown Pike, Plymouth Meeting, PA 19462, USA
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Elevations in serum creatinine with RAAS blockade: why isn't it a sign of kidney injury? Curr Opin Nephrol Hypertens 2009; 17:443-9. [PMID: 18695383 DOI: 10.1097/mnh.0b013e32830a9606] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW The aim of this article is to review the pertinent physiology and pathophysiology of the renin-angiotensin-aldosterone system (RAAS), summarize the proven beneficial cardiovascular and renal effects of RAAS blockade, examine clinical situations in which RAAS blockade may induce reductions in glomerular filtration rate, and explore why increases in serum creatinine in the setting of angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) therapy do not necessarily signify the presence of clinically relevant kidney failure. RECENT FINDINGS RAAS inhibition appears to reduce the likelihood of atrial fibrillation. RAAS inhibition leads to improved insulin sensitivity and glycemic control, but does not appear to prevent diabetes. The beneficial effects of ACEi/ARB therapy extend to those with significant renal disease. Combination ACEi/ARB is safe, and reduces proteinuria more than either agent alone in patients with macroalbuminuric nephropathy. Acute deteriorations in renal function that result from RAAS inhibition are usually reversible. SUMMARY RAAS blockade exerts potent hemodynamic, antihypertensive, and antiinflammatory effects, and slows progression of kidney disease beyond that due to lowering of blood pressure. The benefit extends to those with advanced disease. In spite of established benefit, ACEi and ARB therapy remains underutilized, in part due to concerns about acute deteriorations in renal function that result from interruption of the RAAS.
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