Polypharmacy of heart failure. Creating a rational pharmacotherapeutic protocol

Network medicine in Cardiovascular Research

The ability to generate multi-omics data coupled with deeply characterizing the clinical phenotype of individual patients promises to improve understanding of complex cardiovascular pathobiology. There remains an important disconnection between the magnitude and granularity of these data and our ability to improve phenotype-genotype correlations for complex cardiovascular diseases. This shortcoming may be due to limitations associated with traditional reductionist analytical methods, which tend to emphasize a single molecular event in the pathogenesis of diseases more aptly characterized by crosstalk between overlapping molecular pathways. Network medicine is a rapidly growing discipline that considers diseases as the consequences of perturbed interactions between multiple interconnected biological components. This powerful integrative approach has enabled a number of important discoveries in complex disease mechanisms. In this review, we introduce the basic concepts of network medicine and highlight specific examples by which this approach has accelerated cardiovascular research. We also review how network medicine is well-positioned to promote rational drug design for patients with cardiovascular diseases, with particular emphasis on advancing precision medicine.

Type 2 Diabetes and Chronic Systolic Heart Failure

Diabetes is a chronic progressive endocrinopathy associated with significant macrovascular and microvascular complications as well as cardiomyopathy and heart failure (HF). Diabetes and chronic systolic HF result in similar activation of pathologic neurohormonal pathways. When diabetes and HF coexist, morbidity and mortality significantly increase. This article reviews important clinical issues in the care of patients with diabetes and HF. A review of pertinent pathophysiologic principles is provided, followed by a discussion of the treatment issues related to this population. Treatment issues include vascular disease risk factor modification, HF pharmacotherapy, glycemic management, and control of other common comorbid conditions.

[Patients on multiple medication: do they know the right doses? Do they take their medications correctly?]

OBJECTIVES

To find whether patients on multiple medication attending our consultations know the doses of the medication prescribed them. To verify whether these patients say they have taken the prescribed medication correctly.

DESIGN

Descriptive study through questionnaire given the patient or the carer responsible for the medication.

SETTING

Health centre in the periphery of our city.

PARTICIPANTS

212 patients (104 men and 108 women) under 65 years old and 228 (118 men and 110 women) over this age, under treatment with medication taken orally, rectally or transdermically.

MAIN MEASUREMENTS

Questionnaire in which two questions were asked orally of the patient or carer on each of the medicines prescribed (between 1 and 9): a) how has your doctor said you should take the medicine, and b) how do you really take the medicine? The replies were noted down by the interviewer and then evaluated when the data were checked against the clinical records.

RESULTS

Only 20% of those under 65 who took 8 or 9 medicines remembered correctly the dosages of all of them. 10% of those who took 9 medicines said they took them correctly. 30% of those over 65 who took 8 medicines knew the dosages of all of them. 10% of those who took 9 medicines and 20% of those who took 8 said they took them all correctly.

CONCLUSIONS

In the case of patients on multiple medication, the doctor must try to establish simple dosage patterns (once or twice a day) of the most efficient efficacious medication.

Specialist care of heart failure improves appropriate pharmacotherapy at the expense of greater polypharmacy and drug-interactions

BACKGROUND

There is growing concern at the nature and extent of polypharmacy in heart failure (HF), which may be associated with increased drug interactions, adverse drug effects and a poor understanding of and compliance with therapy.

AIMS

This study evaluates polypharmacy in a relatively unselected community heart failure population following emergency admission and determines the impact of an in-hospital, specialist heart failure care programme on appropriate pharmacotherapy, polypharmacy and drug interactions.

METHODS

We analysed the medication profiles of 91 consecutive patients with an emergency admission for HF to our institution on admission and discharge. The numbers of inappropriate medicines, inappropriate dosages and omitted medicines according to guidelines were recorded. Medication profiles were analysed for potential drug-drug, drug-liver and drug-kidney interactions using standard criteria.

RESULTS

In the study population, average age 71.1+/-10.4 years, 65.9% were male, 68.1% had left ventricular systolic dysfunction and the average ejection fraction on transfer to the specialist HF service was 38+/-13%. A total of 66 inappropriate medicines, 107 omitted medicines and 37 inappropriate dosage regimens were identified in the cohort on admission. These figures had dropped to 31, 33 and 19, respectively, on discharge, with per patient averages decreasing significantly (all P<0.0001). However, polypharmacy and potential drug interactions increased by 33% and 62%, respectively, from admission to discharge (P<0.0001) as did drug-kidney interactions and drug-liver interactions. Only ischemic aetiology and hypercholesterolaemia predicted polypharmacy in this cohort on discharge, whereas age, sex, renal function and heart failure type did not.

CONCLUSIONS

Specialist care of heart failure following emergency admission results in more appropriate pharmacotherapy of heart failure. However, increased polypharmacy and drug-interactions are an inevitable consequence independent of age, sex and renal function. We advocate a practice of systematic evaluation of polypharmacy in all heart failure patients to identify potential problems and modify therapy where appropriate.

High- Versus Low-Dose ACE Inhibitor Therapy in Chronic Heart Failure

OBJECTIVE

To discuss the controversy associated with the optimal dosing of angiotensin-converting enzyme (ACE) inhibitors in the management of patients with systolic heart failure; specifically, to review data related to the use of high-dose ACE inhibitors related to both neurohormonal and clinical outcomes associated with doses similar to, lower than, and higher than those used in the large, randomized clinical trials.

DATA SOURCES

Primary, review, and meta-analysis articles were identified by MEDLINE search (1987–September 2002) and through secondary sources.

STUDY SELECTION AND DATA EXTRACTION

All of the articles identified from the data sources were evaluated, and all information deemed relevant was included in this discussion. All available comparative dose trials, both prospective and retrospective, were evaluated for clinical and neurohormonal outcomes.

DATA SYNTHESIS

The majority of data comparing the effect of high- with low-dose ACE inhibitors on neurohormonal outcomes demonstrate dose-related reduction in various neurohormonal measurements including plasma ACE, aldosterone, atrial natriuretic peptide, B-type natriuretic peptide, and interleukin-6 levels. Clinical endpoints including New York Heart Association class and heart failure—related hospitalizations were reduced by higher doses, but a dose-related survival benefit has not been demonstrated. Differences in duration of therapy and study design may account for variability in neurohormonal and morbidity results among various studies.

CONCLUSIONS

Despite documented underutilization in clinical practice of doses of ACE inhibitors demonstrated in large controlled trials to improve morbidity and mortality, clinicians should attempt to reach these target doses if possible in patients with heart failure. Higher doses may improve surrogate markers for heart failure without impacting survival.