scholarly journals Analysing registries in heart failure: The case of angiotensin receptor blockers in Asians with heart failure with reduced ejection fraction

2018 ◽  
Vol 257 ◽  
pp. 224-225
Author(s):  
Pardeep S. Jhund
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Angiotensin Receptor Blockers ◽  
Angiotensin Receptor ◽  
Reduced Ejection Fraction ◽  
Receptor Blockers

Abstract 343: Trends and Predictors of Use of Angiotensin Receptor Blocker and Neprilysin Inhibitor in Patients With Heart Failure

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Supriya Shore ◽  
Tanima Basu ◽  
Neil Kamdar ◽  
Patrick Brady ◽  
Scott L Hummel ◽  
...  
Keyword(s):  
Heart Failure ◽  
Enzyme Inhibitors ◽  
Angiotensin Receptor Blockers ◽  
Angiotensin Converting Enzyme Inhibitors ◽  
Angiotensin Receptor ◽  
Converting Enzyme Inhibitors ◽  
Reduced Ejection Fraction ◽  
Neprilysin Inhibitor ◽  
Patients With Heart Failure ◽  
Receptor Blockers

Objective: Current guidelines recommend use of combination therapy with angiotensin receptor blocker and neprilysin inhibitor (ARNI) (i.e., Entresto ® ) in patients with heart failure (HF) with reduced ejection fraction as a class 1 recommendation. Contemporary data on real-world use of these agents is lacking. Methods: This is a retrospective cohort study of individuals enrolled in Clinformatics® Data Mart Database (OptumInsight, Eden Prairie, MN from January 1, 2016 to December 31, 2018. We included all individuals ≥ 18 years, with two outpatient encounters or one inpatient encounter with a principal ICD 10 diagnosis for HFand 6 months of continuous enrollment. To further identify patients with reduced ejection fraction, we only included individuals who received prescriptions for beta-blockers and angiotensin converting enzyme inhibitors/ angiotensin receptor blockers. Comorbidities were identified using Elixhauser comorbidity index.. Multivariate logistic regression model was used to identify predictors of ARNI use. Results: A total of 154,777 patients were included in our cohort. Overall, 5,834 patients (3.8%) received an ARNI prescription. Use of ARNI increased from 1.4% in 2016 to 3.9% in 2018 (p<0.01). Compared to patients receiving angiotensin converting enzyme inhibitors/angiotensin receptor blockers, patients receiving ARNI were younger (mean age 69.4 ± 11.1 vs. 72.9 ± 11.0 years;), more likely to be male (69.3% vs. 54.4%) and have commercial insurance (22.1% vs. 16.7%) with a higher comorbidity burden. Predictors of ARNI use after multivariable adjustment included age<65 years (OR 1.4; 95% CI 1.3-1.5), Male sex (OR 1.8; 95% CI 1.7 - 1.9) and black race (OR 1.2; 95% CI 1.1 - 1.2). Other predictors of ARNI use are shown in Figure 1. Patients receiving care through a cardiologist compared to a primary care physician were more likely to receive an ARNI (OR 1.8; 95% 1.7 - 1.9). Out of pocket cost for ARNI ranged from $0 to $1006 per month (median $44; IQR $9-$60). Conclusion: Rates of ARNI use remain low among patients with heart failure with racial and gender disparities. Heart Failure patients receiving care with a cardiologist were more likely to receive ARNI. Out of pocket cost for this medication remains high and may be a significant barrier to its use.

scholarly journals Safety and Tolerability of Initiating Maximum-Dose Sacubitril-Valsartan in Patients on Target Dose Renin-Angiotensin System Inhibitors

2019 ◽  
Vol 2019 ◽  
pp. 1-6 ◽  
Author(s):  
Helena Norberg ◽  
Ellinor Bergdahl ◽  
Krister Lindmark
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Ace Inhibitors ◽  
Maximum Dose ◽  
Angiotensin Receptor Blockers ◽  
Renin Angiotensin System ◽  
Target Dose ◽  
Reduced Ejection Fraction ◽  
Receptor Blockers

Aim. Sacubitril-valsartan has proven beneficial in heart failure with reduced ejection fraction. Guidelines recommend initiating half-dose sacubitril-valsartan before up-titration even to patients already on target dose angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB). To reduce the number of titration steps needed in order to simplify for the patient as well as the clinic, we aimed to investigate the safety and tolerability of switching patients on target dose ACE inhibitors or ARBs directly to maximum-dose sacubitril-valsartan. Methods. This prospective cohort study was conducted between April 2016 and November 2017. A total of 66 patients with heart failure and reduced ejection fraction already on guideline-recommended target dose ACE inhibitors or ARBs (equivalent to enalapril 10 mg twice daily) were switched to maximum-dose sacubitril-valsartan (200 mg twice daily). The patients were followed for twelve months. Results. Patients had a mean age of 72 ± 10 years, mean systolic blood pressure of 121 ± 17 mmHg, and 92% were male. At 12-month follow-up, nine patients (14%) had discontinued sacubitril-valsartan, four patients (6%) had a dose reduction, and 17 patients (26%) had developed symptomatic hypotension. No angioedema occurred within the 12-month follow-up and there were no hospitalizations or emergency room visits within the first 14 days. Conclusions. Switching directly from target dose ACE inhibitors or ARBs to maximum-dose sacubitril-valsartan was safe and generally well tolerated.

Outcomes of a Pharmacist-Managed Heart Failure Medication Titration Assistance Clinic

2018 ◽  
Vol 52 (8) ◽  
pp. 724-732 ◽  
Author(s):  
Shubha Bhat ◽  
Mayank Kansal ◽  
George T. Kondos ◽  
Vicki Groo
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Ace Inhibitors ◽  
Chart Review ◽  
Ace Inhibitor ◽  
Angiotensin Receptor Blockers ◽  
Retrospective Chart Review ◽  
National Guidelines ◽  
Reduced Ejection Fraction ◽  
Receptor Blockers

Background: National guidelines recommend angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) and β-blockers (BBs) at target doses for morbidity and mortality benefits in heart failure with reduced ejection fraction (HFrEF); regardless, titration of these therapies in practice remains suboptimal. We implemented an outpatient pharmacist-managed HFrEF medication titration assistance clinic (MTAC) at one institution to improve titration for general cardiology (GC) patients. Objective: To evaluate MTAC impact by determining the proportion of patients on target or maximum tolerated ACE inhibitor/ARB and BB doses. Methods: A retrospective chart review of adult patients with documented ejection fraction ≤40% managed in the MTAC or GC from 2011 to 2013 was conducted. HFrEF medication regimens were collected at initial visit and months 1, 2, 3, 6, 9, and 12 to assess titration. Target doses were defined per guideline or dose at which ejection fraction recovered during the study. Maximum tolerated doses were defined as the highest dose patients tolerated without physiological limitations. Results: Of 148 patients, the MTAC managed 51 and GC managed 97. At baseline, 90% of MTAC versus 82% of GC patients were prescribed ACE inhibitors/ARBs and BBs. In the MTAC, 4% were at target or maximum tolerated doses compared with 32% of GC patients ( P < 0.001). At 12 months, 95% of patients in the MTAC and 87% in GC were prescribed ACE inhibitors/ARBs and BBs. Of those prescribed ACE inhibitors/ARBs and BBs, 64% in the MTAC versus 40% in GC reached target or maximum tolerated doses ( P = 0.01). Conclusions: The pharmacist-managed MTAC increased the proportion of patients on optimal HFrEF therapies and are a resource for GC patients.

Evaluation of the Usage and Dosing of Guideline-Directed Medical Therapy for Heart Failure With Reduced Ejection Fraction Patients in Clinical Practice

2021 ◽  
pp. 089719002110048
Author(s):  
Katelyn V. Smith ◽  
Jacqueline R. Dunning ◽  
Christina M. Fischer ◽  
Taylor E. MacLean ◽  
Joshua W. Bosque-Hamilton ◽  
...  
Keyword(s):  
Heart Failure ◽  
Quality Improvement ◽  
Ejection Fraction ◽  
Beta Blockers ◽  
Angiotensin Receptor Blockers ◽  
Academic Medical Center ◽  
Angiotensin Receptor ◽  
Improvement Project ◽  
Reduced Ejection Fraction ◽  
Tertiary Center

Background: Although strategies for optimization of pharmacologic therapy in patients with heart failure with reduced ejection fraction (HFrEF) are scripted by guidelines, data from HF registries suggests that guideline-directed medical therapies (GDMT) are underutilized among eligible patients. Whether this discrepancy reflects medication intolerance, contraindications, or a quality of care issue remains unclear. Objective: The objective of this initiative was to identify reasons for underutilization and under-dosing of HFrEF therapy in patients at a large, academic medical center. Methods: Among 500 patients with HFrEF enrolled in a quality improvement project at a tertiary center, we evaluated usage and dosing of 4 categories of GDMT: ACE inhibitors/Angiotensin Receptor Blockers (ACE-i/ARB), Angiotensin Receptor-Neprilysin Inhibitors (ARNi), beta blockers, and Mineralocorticoid Receptor Antagonists (MRA). Reasons for nonprescription and usage of suboptimal doses were abstracted from notes in the chart and from telephone review of previous medication trials with the patient. Results: Of 500 patients identified, 472 subjects had complete data for analysis. Among eligible patients, ACE-i/ARB were prescribed in 81.4% (293 of 360) and beta blockers in 94.4% (442 of 468). Of these patients, 10.6% were prescribed target doses of ACE-i/ARB and 12.4% were prescribed target doses of beta blockers. Utilization of other categories of GDMT was lower, with 54% of eligible patients prescribed MRAs and 27% prescribed an ARNi. In most cases, the reasons for nonprescription or under-dosing of GDMT were not apparent on review of the health record or discussion with the patient. Conclusion: Clear rationale for nonprescription and under-dosing of GDMT often cannot be ascertained from detailed review and is only rarely related to documented medication intolerance or contraindications, suggesting an opportunity for quality improvement.

SGLT-2-Inhibitors in Heart Failure

2020 ◽  
pp. 1-4
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Enzyme Inhibitors ◽  
Therapeutic Option ◽  
Angiotensin Receptor Blockers ◽  
Angiotensin Converting Enzyme Inhibitors ◽  
Converting Enzyme Inhibitors ◽  
Reduced Ejection Fraction ◽  
Effective Therapeutic Option ◽  
Receptor Blockers

Heart failure is a frequent and highly debilitating pathology. Angiotensin‐converting enzyme inhibitors and angiotensin receptor blockers, β‐ blockers, mineralocorticoid receptor antagonists, and valsartan/sacubitril have been shown to reduce mortality in chronic heart failure with reduced ejection fraction. Recently, glifozines (SGLT‐2 inhibitors) have become another effective therapeutic option for heart failure with reduced ejection fraction, in patients with and without diabetes mellitus. The review presents the effects of SGLT‐2 inhibitors on the cardiovascular system and heart failure.

Impact of Clinical Audit on Adherence to the Guidelines Directed Medical Therapy in Patients Admitted with Heart Failure

2020 ◽  
Vol 15 (2) ◽  
pp. 117-123
Author(s):  
Aashiq A. Shukkoor ◽  
Nimmy E. George ◽  
Shanmugasundaram Radhakrishnan ◽  
Sivakumar Velusamy ◽  
Tamilarasu kaliappan ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Acute Heart Failure ◽  
Medical Therapy ◽  
Clinical Audit ◽  
Angiotensin Receptor Blockers ◽  
Angiotensin Receptor ◽  
Converting Enzyme Inhibitors ◽  
Reduced Ejection Fraction ◽  
The Impact

Background: The adoption of guideline recommendations of pharmacotherapy to improve the clinical course of Heart Failure (HF) remains below par. Our objective is to evaluate the impact of clinical audit on adherence to the Guideline-Directed Medical Therapy (GDMT) in patients admitted with acute heart failure with reduced ejection fraction (EF). Methods: A prospective interventional study was conducted over a period of 12 months from June 2018 to May 2019 in all patients admitted with acute heart failure with reduced ejection fraction. The discharge prescriptions of patients who met the inclusion criteria were audited for appropriateness in the usage of neurohormonal blockers and Ivabradine, by a clinical pharmacist on a monthly basis. Audit results were presented to the practicing physicians every month and feedback was given. Results: Discharge prescriptions of 716 patients who presented with HF were audited for the reasonable or unreasonable omission of neurohormonal blocking drugs. The first-month audit revealed that the unreasonable omission of Angiotensin-Converting Enzyme Inhibitors/ Angiotensin Receptor Blockers/ Angiotensin Receptor Neprilisin Inhibitors ( ACEI/ARB/ARNI), Betablockers and Mineralocorticoid Receptor Antagonists (MRA) were 24.5%, 13.1%, and 9.09% respectively, which reduced to nil at the end of the study period (p=0.00). Initiation of Ivabradine before prescribing or achieving the target dose of Betablocker was noted in 38.18% of patients in the first month, which was also reduced to nil (p=0.00) at the end of the study. Conclusion: This study reveals that periodic clinical audit improves adherence to GDMT in patients admitted with heart failure with reduced ejection fraction.

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