Adherence to treatment guidelines in the pharmacological management of chronic heart failure in an Australian population

Challenges to heart failure medication prescribing post-hospitalization

OBJECTIVES

To determine the prevalence of heart failure (HF) medication prescribing on discharge post-HF-related admission.

METHODS

A retrospective audit was conducted for 216 HF admissions over a period of 6 months; medication data from electronic records were collected for analysis.

KEY FINDINGS

The prevalence of HF medication prescribing on discharge was: 32.9% (95% confidence interval: 26.6-39.6) renin-angiotensin-aldosterone system inhibitors, 10.6% (6.9-15.6) angiotensin receptor-neprilysin inhibitors, 31.5% (25.4-38.1) HF-specific beta-blockers, 42.6% (35.9-49.5) aldosterone receptor antagonists, and 11.6% (7.6-16.6) sodium-glucose cotransporter-2 inhibitors.

CONCLUSION

HF medication prescribing remains relatively low despite the known benefits and recommendations listed in the guidelines.

Guideline-based audit of the hospital management of heart failure with reduced ejection fraction

BACKGROUND

Heart failure is a major burden in Australia in terms of morbidity, mortality and healthcare expenditure. Multiple evidence-based therapies are recommended for heart failure with reduced ejection fraction (HFrEF), but data on physician adherence to therapy guidelines are limited.

AIM

To compare use of HFrEF therapies against current evidence-based guidelines in an Australian hospital inpatient population.

METHODS

A retrospective review of patients admitted with a principal diagnosis of HFrEF across six metropolitan hospitals in Sydney, Australia, between January 2015 and June 2016. Use of medical and device therapies was compared with guideline recommendations using individual patient indications/contraindications. Readmission and mortality data were collected for a 1-year period following the admission.

RESULTS

Of the 1028 HFrEF patients identified, 39 were being managed with palliative intent, leaving 989 patients for the primary analysis. Use of beta-blockers (87.7% actual use/93.6% recommended use) and diuretics (88.4%/99.3%) was high among eligible patients. There were large evidence-practice gaps for angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB; 66.4%/89.0%) and aldosterone antagonists (41.0%/77.1%). In absolute terms, use of these therapies each increased by over 11% from admission. Ivabradine (11.5%/21.2%), automated internal cardiac defibrillators (29.5%/66.1%) and cardiac resynchronisation therapy (13.1%/28.7%) were used in a minority of eligible patients. Over the 1-year follow-up period, the mortality rate was 14.8%, and 44.2% of patients were readmitted to hospital at least once.

CONCLUSION

Hospitalisation is a key mechanism for initiation of HFrEF therapies. The large evidence-practice gaps for ACEI/ARB and aldosterone antagonists represent potential avenues for improved HFrEF management.

An audit of adherence to heart failure guidelines in an Australian hospital: A pharmacist perspective

RATIONALE, AIMS, AND OBJECTIVES

The Australian National Heart Foundation Guidelines have been developed to guide clinicians on how to best manage chronic heart failure (CHF) patients according to the current best available evidence. The primary aim of this study is to evaluate the proportion of patients prescribed evidence-based therapy (EBT) for CHF on discharge at this Australian metropolitan hospital and factors affecting its prescribing. The secondary aims are to examine the proportion of patients prescribed EBT on discharge on cardiac wards compared to medical wards and to explore the role of the pharmacist in the management of these patients.

METHOD

A retrospective audit of patients' medical notes who were admitted consecutively for CHF management was conducted over 6 months to examine their management.

RESULTS

The results showed at discharge, a total of 52% of patients were discharged on angiotensin converting enzyme inhibitors/angiotensin receptor blockers, 49% were discharged on β-blockers, 15% were on Aldosterone receptor antagonists, 90% were discharged on diuretics, and 29% were discharged on Digoxin. The main determinants of prescribing EBT on discharge were the presence of prescribing contraindications and patients' comorbidities. Patients discharged from cardiac wards were more likely to be prescribed EBT than if discharged on medical wards. Furthermore, in the subset of the cohort who was reviewed by a pharmacist during admission, a higher percentage of patients were discharged on EBT compared with those who did not have a pharmaceutical input.

CONCLUSION

This study highlighted existing gaps between the National CHF Guidelines and clinical prescribing practice in this hospital. Patients who were discharged from cardiac wards were more likely to be prescribed medications concordant with the guidelines, and there is further opportunity for pharmacists to assist in closing gaps in prescribing practice by the promotion of adherence to these guidelines.

Understanding the Epidemiology of Heart Failure to Improve Management Practices: An Asia-Pacific Perspective

Heart failure (HF) is a major global healthcare problem with an estimated prevalence of approximately 26 million. In Asia-Pacific regions, HF is associated with a significant socioeconomic burden and high rates of hospital admission. Epidemiological data that could help to improve management approaches to address this burden in Asia-Pacific regions are limited, but suggest patients with HF in the Asia-Pacific are younger and have more severe signs and symptoms of HF than those of Western countries. However, local guidelines are based largely on the European Society of Cardiology and American College of Cardiology Foundation/American Heart Association guidelines, which draw their evidence from studies where Western patients form the major demographic and patients from the Asia-Pacific region are underrepresented. Furthermore, regional differences in treatment practices likely affect patient outcomes. In the following review, we examine epidemiological data from existing regional registries, which indicate that these patients represent a distinct subpopulation of patients with HF. In addition, we highlight that patients with HF are under-treated in the region despite the existence of local guidelines. Finally, we provide suggestions on how data can be enriched throughout the region, which may positively affect local guidelines and improve management practices.

Beta-blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, nitrate-hydralazine, diuretics, aldosterone antagonist, ivabradine, devices and digoxin (BANDAID(2) ): an evidence-based mnemonic for the treatment of systolic heart failure

Heart failure causes significant morbidity and mortality, with recognised underutilisation rates of guideline-based therapies. Our aim was to review current evidence for heart failure treatments and derive a mnemonic summarising best practice, which might assist physicians in patient care. Treatments were identified for review from multinational society guidelines and recent randomised trials, with a primary aim of examining their effects in systolic heart failure patients on mortality, hospitalisation rates and symptoms. Secondary aims were to consider other clinical benefits. MEDLINE and EMBASE were searched using a structured keyword strategy and the retrieved articles were evaluated methodically to produce an optimised reference list for each treatment. We devised the mnemonic BANDAID (2) , standing for beta-blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, nitrate-hydralazine (or potentially neprilysin inhibitor), diuretics, aldosterone antagonist, ivabradine, devices (automatic implantable cardioverter defibrillator, cardiac resynchronisation therapy or both) and digoxin as a representation of treatments with strong evidence for their use in systolic heart failure. Treatment with omega-3 fatty acids, statins or anti-thrombotic therapies has limited benefits in a general heart failure population. Adoption of this mnemonic for current evidence-based treatments for heart failure may help improve prescribing rates and patient outcomes in this debilitating, high mortality condition.

Chronic Heart Failure Clinical Practice Guidelines' Class 1-A Pharmacologic Recommendations: Start-to-End Synergistic Drug Therapy?

BACKGROUND

Chronic heart failure (HF) disease as an emerging epidemic has a high economic-psycho-social burden, hospitalization, readmission, morbidity and mortality rates despite many clinical practice guidelines' evidenced-based and consensus driven recommendations that include trials' initial-baseline data.

OBJECTIVE

To show that the survival and hospitalization-free event rates in the reviewed chronic HF clinical practice guidelines' class I-A recommendations as initial HF drug therapy (IDT) is possibly a combination and 'start-to-end' synergistic effect of the add-on ('end') HF drug therapy (ADT) to the baseline ('start') HF drug therapy (BDT).

METHODOLOGY

The references cited in the chronic HF clinical practice guidelines of the 2005, 2009, and 2013 American Heart Association/American College of Cardiology (AHA/ACC), the 2006 Heart Failure Society of America (HFSA), and the 2005, 2008, and 2012 European Society of Cardiology (ESC) were reviewed and compared with the respective guidelines' and other countries' recommendations.

RESULTS

The BDT using glycosides and diuretics is 79%-100% in the cited HF trials. The survival rates attributed to the BDT ('start') is 46%-89% and IDT ('end') 61%-92.8%, respectively. The hospitalization-free event rate of the BDT group: 47.1% to 85.3% and IDT group 61.8%-90%, respectively. Thus, the survival and hospitalization-free event rates of the ADT is 0.4%-15% and 4.6% to 14.7%, respectively. The extrapolated BDT survival is 8%-51% based on a 38% estimated natural HF survival rate for the time period109.

CONCLUSION

The contribution of baseline HF drug therapy (BDT) is relevant in terms of survival and hospitalization-free event rates compared to the HF class 1-A guidelines initial drug therapy recommendations (IDT). Further, the proposed initial HF drug ('end') therapy (IDT) has possible synergistic effects with the baseline HF drug ('start') therapy (BDT) and is essentially the add on HF drug therapy (ADT) in our analysis. The polypharmacy HF treatment is a synergistic effect due to BDT and ADT.

Potential New Agents for the Management of Hyperkalemia

Hyperkalemia is a common electrolyte disturbance with multiple potential etiologies. It is usually observed in the setting of reduced renal function. Mild to moderate hyperkalemia is usually asymptomatic, but is associated with poor prognosis. When severe, hyperkalemia may cause serious acute cardiac arrhythmias and conduction abnormalities, and may result in sudden death. The rising prevalence of conditions associated with hyperkalemia (heart failure, chronic kidney disease, and diabetes) and broad use of renin-angiotensin-aldosterone system (RAAS) inhibitors and mineralocorticoid receptor antagonists (MRAs), which improve patient outcomes but increase the risk of hyperkalemia, have led to a significant rise in hyperkalemia-related hospitalizations and deaths. Current non-invasive therapies for hyperkalemia either do not remove excess potassium or have poor efficacy and tolerability. There is a clear need for safer, more effective potassium-lowering therapies suitable for both acute and chronic settings. Patiromer sorbitex calcium and sodium zirconium cyclosilicate (ZS-9) are two new potassium-lowering compounds currently in development. Although they have not yet been approved by the US FDA, both have demonstrated efficacy and safety in recent trials. Patiromer sorbitex calcium is a polymer resin and sorbitol complex that binds potassium in exchange for calcium; ZS-9, a non-absorbed, highly selective inorganic cation exchanger, traps potassium in exchange for sodium and hydrogen. This review discusses the merits of both novel drugs and how they may help optimize the future management of patients with hyperkalemia.

[Results of implementing a programme to improve the quality of the contents in hospital discharge reports in cases of heart failure]

OBJECTIVES

To analyse the information collected in hospital discharge reports (HDR) that are given to patients with a diagnosis of heart failure (HF), and demonstrate the improvement in the content of these reports after the introduction of an intervention.

MATERIAL AND METHODS

HDR with HF as the main diagnosis issued by the Department of Internal Medicine were analysed, and the presence of the diagnosis, prognosis and therapeutic data in these HDR was compared in a sample before and after the intervention, which consisted of reporting the results of analysis of the initial sample to the physicians.

RESULTS

A total of 651 HDR (371 pre-intervention and 280 post-intervention) were analysed. Most of the HDR (over 70%) did not include the functional class. Most of the HDR did not include information about echocardiogram performed before the hospitalization period analysed, and most of the HDR that collected this information did not determine if the HF was diastolic or systolic. In the post-intervention sample there was a lower percentage of HDR that prescribed angiotensin-converting enzyme inhibitors or angiotensin receptor blocker ii (26% vs 32%, P<.001). In 30% of the pre-intervention sample and 38% of the post-intervention sample there was indication of beta-blockers (P=.027).

CONCLUSIONS

A short discussion with the physicians responsible for patients with HF improves the inclusion of important data on the diagnosis, prognosis and treatment in the HDR.

Clinical effects of Xinmailong therapy in patients with chronic heart failure

In the last 100 years, intensive studies have been done on the identification of the systematic approaches to find the cure for the chronic heart failure, however the mystery remains unresolved due to its complicated pathogenesis and ineffective early diagnosis. The present investigation was aimed to evaluate the potential effects of the traditional chinese medicine, Xinmailong, on the chronic heart failure (CHF) patients as compared to the standard western medical treatment available so far. In our study, we selected two groups of voluntary CHF patients at the Xiangya Hospital, which were allowed to administrate Xinmailong or standard treatments, respectively. Another group of voluntary healthy individuals were recruited as the control group. The treatment effectiveness was measured by five symptomatic factors, i.e. angiotensin II (Ang_II), high sensitivity C-reactive protein (hs_CRP), Left Ventricular End Systolic Volume Index (LVESVI), left ventricular ejection fraction (LVEF) and pro-B-type natriuretic peptide (NT_proBNP), between the control group and the CHF patients at different stages of drug administration and in different treatment groups. The timeline for the full dose administration was set to 15 days and five measurements as indicated above were taken on every 0, 7th and 15th day of the drug administration respectively. In the conducted study, similar symptomatic measurements were observed on day 0 in both treatment groups, and slight improvements were observed on 7th day. It was observed that after a full course of drug administration for 15 days, both of the treatment groups achieved statistically significant improvements in all the five measures, but Xinmailong was found to be more (almost double) statistically significant as compared with the available drug treatments for chronic heart failure.