Background:
Mineralocorticoid receptor antagonists (MRAs) are an important component of guideline-directed therapy for patients with heart failure with a reduced ejection fraction (HFrEF) but are underutilized in clinical practice. Hospitalization is a quality-improvement opportunity to increase appropriate use of MRAs, particularly as this therapy is associated with reduced readmission following both hospitalizations with a principal and secondary diagnosis of heart failure. We studied MRA prescription for heart failure patients before and after hospitalization.
Methods:
We performed a retrospective cohort study of adults hospitalized within an academic tertiary-care hospital system in 2013-2015 with a principal or secondary discharge diagnosis of heart failure. We included patients with ejection fraction ≤35%, systolic blood pressure ≥100 mm Hg, estimated glomerular filtration rate >30 ml/min/1.73 m
2
, and potassium <5.0 mEq/L. We recorded MRA prescription before and after hospitalization. We used McNemar’s test to compare MRA prescription before and after hospitalization, with pre-specified principal and secondary diagnosis subgroups. We used the chi-square test to compare prescriptions between groups.
Results:
Among 1176 hospitalizations of patients who met the inclusion criteria, the mean age was 72.7±13.4 years and 366 (31%) were female. Of these patients, 303 (25.8%) were prescribed MRAs prior to hospitalization and 331 (28.2%) were prescribed them at discharge, a small but statistically significant increase (p=0.02). Among patients previously prescribed MRAs, 241 (79.5%) continued them at discharge. Among 873 patients not previously prescribed MRAs, 90 (10.3%) had MRAs initiated at discharge.
Among 347 patients with a principal diagnosis of heart failure, 95 had MRAs continued, 27 had MRAs discontinued, and 39 had MRAs initiated, a non-significant increase of 12 patients (+3.6%, p=0.14). Among 829 patients with a secondary diagnosis, 146 had MRAs continued, 35 had MRAs discontinued, and 51 had MRAs initiated, a non-significant increase of 16 patients (+1.9%, p=0.08). More patients with a principal diagnosis received MRAs at discharge: 134/347 (38.6%) compared to 197/829 (23.7%) patients discharged with a secondary diagnosis of HFrEF, p<0.0001; similarly, patients with a principal diagnosis of HFrEF had higher rates of MRA initiation at discharge: 39/225 (17.3%) versus 51/648 (7.9%), p=0.0004.
Conclusions:
Over 70% of hospitalized HFrEF patients did not receive MRAs before or after hospitalization. Although more patients with a principal diagnosis than secondary diagnosis of heart failure received MRAs and had them initiated, over 80% of eligible patients not on MRAs were not initiated on them at discharge. Hospitalization remains an opportunity to identify patients indicated for MRAs and initiate guideline-directed heart failure pharmacotherapy.
Importance of the time of initiation of mineralocorticoid receptor antagonists on risk of mortality in patients with heart failure
