Aldosterone Antagonists: Evidence-Based Yet Underutilized Effective Heart Failure Therapy

Background: The 2017 AHA/ACC/HFSA Focused Update of the 2013 ACC/AHA Guidelines for the Management of Heart Failure provided additional support for the clinical use of ACEI, ARBs or ARNIs in conjunction with Evidence-Based Beta Blockers and Aldosterone Antagonists in HFrEF, otherwise known as Guideline-Directed Medical Therapy (GDMT). Although these updates clarified the benefits of GDMT to patient outcomes, low rates of adherence at the provider level for both hospitalized and ambulatory patients continue to be seen. Methods: With the objective of rapidly improving GDMT utilization, as well as improving patient outcomes, the American Heart Association initiated a multidisciplinary collaborative in three metropolitan markets - Chicago, Milwaukee, and St. Louis. Utilizing Get With The Guidelines®-Heart Failure (GWTG-HF), 40 hospitals tracked patients discharged with a primary diagnosis of heart failure and entered data from their inpatient and 30-days post-acute record. An initiative benchmark group was created to track progress and revisions were made to the post-acute care form. Hospitals were provided targeted consultation using hospital-specific data compared to regional and initiative benchmarks. The initiative provided exclusive professional education, including webinars, collaboration meetings, and best-practice recommendations. Results: Between January 1, 2019 and December 31, 2019, 10,532 patients with a primary diagnosis of heart failure, were entered into GWTG-HF from the 40 initiative hospitals, in which 3807 had an EF of <40%. A comparison from Q1 to Q4, 2019 of the mean adherence for GDMT was performed at discharge and yielded the following results: ACEI/ARB or ARNi from 89.3% to 91.6%, Evidenced-Based Beta Blockers from 90.3% to 94.2% and Aldosterone Antagonist from 53.6% to 64.7%; At 30-Days the mean adherence for Q1 and Q4 were calculated as follows: ACEI/ARB or ARNi from 60.4% to 72.9% and Aldosterone Antagonist from 28.2% to 55.3%. Evidence-Based Beta Blocker was only captured for Q3 and Q4, 2019 and the mean adherence improved from 70.3% to 73.8%. Conclusions: The multi-city quality initiative early results show a positive correlation in improving adherence to GDMT in both the hospital and ambulatory setting.

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Abstract 268: Multidisciplinary Approach to the Heart Failure Patient Significantly Improves Adherence to Evidence-Based Medicine Beyond Core Measures

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.5.suppl_1.a268 ◽

2012 ◽

Vol 5 (suppl_1) ◽

Author(s):

George G Sokos ◽

Jessica Lazar ◽

Terri Hilliard ◽

Evelyn Ozanich ◽

Amresh Raina ◽

...

Keyword(s):

Heart Failure ◽

Multidisciplinary Team ◽

Multidisciplinary Approach ◽

Variable Cost ◽

Quality Improvement Initiative ◽

Evidence Based ◽

Post Discharge ◽

Post Intervention ◽

Aldosterone Antagonists ◽

Core Measures

Background: Adherence to heart failure core measures has been a focus of all hospitals in the past several years and has become even more important with the advent of pay for performance. Core measures address basic heart failure care, but do not include utilization of all evidence-based therapies which improve long term outcomes. We hypothesized that an in-hospital multidisciplinary heart failure (HF) management program could improve adherence to evidence-based guidelines beyond core measures. Methods: As a quality improvement initiative, we formed a multidisciplinary team to improve compliance with HF evidence-based therapy. Interventions included multiple educational sessions, discharge and post-discharge transition improvements, concurrent and post-discharge chart abstraction, revised patient education, and real-time provider education. Charts were abstracted in 525 consecutive HF inpatients between Jul 2010 and Mar 2011. Data was collected in the GWTG-HF (Outcome Inc) Registry. Pre-intervention compliance data (Jul-Sep) was compared to post-intervention (Nov-Mar) data with a paired t test and the Mann-Whitney rank sum test. Direct variable cost was analyzed for defect-free cases versus cases with defects. Results: Baseline Demographics: Mean age was 69 years, 42% female, 20% black, 55% ischemic etiology, mean LVEF=37%. Prior to the multidisciplinary intervention, overall defect-free care was excellent at over 89% (see figure) but there was a relative underutilization of aldosterone antagonists, hydralazine/nitrate therapy, CRT-D and anticoagulation for AF. Post-intervention, adherence improved to over 90% for all 8 evidence based therapies including: evidence-based beta-blocker (p=0.002), aldosterone antagonist (p<0.001), hydralazine nitrate (p=0.04), ICD placed or prescribed (p<0.001), CRT-D (p=0.002), anticoagulation for afib (p=0.04), and DVT prophylaxis (p=0.04). Mean direct variable cost per case was higher at $8249 in defect cases versus $6951 in defect-free cases. Conclusions: In this single center experience, interventions led by a HF multidisciplinary team can significantly improve adherence to evidence-based therapies, beyond core HF measures. A multidisciplinary approach to inpatient HF care has the potential to decrease HF related costs.

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SHORT-TERM EFFECT OF EVIDENCE-BASED MEDICINE HEART FAILURE THERAPY ON GLOMERULAR FILTRATION RATE IN ELDERLY PATIENTS WITH CHRONIC CARDIORENAL SYNDROME

Journal of the American Geriatrics Society ◽

10.1111/j.1532-5415.2009.02599.x ◽

2009 ◽

Vol 57 (12) ◽

pp. 2385-2386 ◽

Cited By ~ 3

Author(s):

Filip MÃ¡lek ◽

Martin Havrda ◽

Zuzana FruhaufovÃ¡ ◽

Jana VrÃ¡novÃ¡

Keyword(s):

Heart Failure ◽

Glomerular Filtration Rate ◽

Elderly Patients ◽

Filtration Rate ◽

Cardiorenal Syndrome ◽

Term Effect ◽

Evidence Based ◽

Heart Failure Therapy ◽

Short Term ◽

Based Medicine

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Treatment optimization of beta-blockers in chronic heart failure therapy

Scientific Reports ◽

10.1038/s41598-020-72836-4 ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Yirga Legesse Niriayo ◽

Solomon Weldegebreal Asgedom ◽

Gebre Teklemariam Demoz ◽

Kidu Gidey

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Heart Disease ◽

Chronic Heart Failure ◽

Ischemic Heart Disease ◽

Beta Blocker ◽

Beta Blockers ◽

Evidence Based ◽

Heart Failure Therapy ◽

Evidence Based Guidelines

Abstract Although evidence based guidelines recommend optimal use of beta blockers in all patients with chronic heart failure unless contraindicated, they are often underutilized and/or prescribed below the recommended dosage in the majority of patients with heart failure. To our knowledge, however, the optimal use of beta-blockers in chronic heart failure is not investigated in Ethiopia. Therefore, the aim of our study was to investigate the utilization and optimization of beta blockers in the management of patients with chronic heart failure in Ethiopia. A prospective observational study was conducted among ambulatory patients with chronic heart failure in Ethiopia. We included adult patients with a diagnosis of heart failure with a baseline left ventricular ejection fraction < 40% who had been on follow-up for at least 6 months. Patients were recruited into the study during their appointment for medication refilling using simple random sampling technique. All patients were followed for at least 6 months to determine the optimal use of beta blockers. The optimal use of beta blockers was determined according to evidence based guidelines. After explaining the purpose of the study, we obtained written informed consent from all participants. Data were collected through patient interview and review of patients’ medical records. Binary logistic regression analysis was performed to identify factors associated with utilization of beta blockers. A total of 288 patients were included in the study. Out of the total, 67% of the patients were receiving beta blockers. Among the patients who received beta blockers, 34.2% were taking guideline recommended beta blockers while 65.8% were taking atenolol, which is not guideline recommended beta blocker. Among the patients who received guideline recommended beta blockers, only 3% were taking optimal dose. Prior hospitalization [Adjusted Odds ratio (AOR) 0.38, 95% confidence interval (CI) 0.19–0.76], dose of furosemide > 40 mg (AOR 0.39, 95% CI 0.20–0.76), ischemic heart disease (AOR 3.27, 95% CI 1.66–6.45), atrial fibrillation (AOR 4.41, 95% CI 1.38–14.13) were significantly associated with the utilization of beta-blockers. Despite proven benefit, beta blockers were not optimally used in most of the participants in this study. The presence of ischemic heart disease and atrial fibrillation were positively associated with the utilization of beta blockers while hospitalization and higher diuretic dose were negatively associated with the utilization of beta blockers. Clinicians should attempt to use evidence based beta blockers at guideline recommended target doses that have been shown to have morbidity and mortality benefit in chronic heart failure. Moreover, more effort needs to be done to minimize the potentially modifiable risk factors for underutilization of beta blocker in chronic heart failure therapy.

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Effect of cardiologist care on 6-month outcomes in patients discharged with heart failure: results from an observational study based on administrative data

BMJ Open ◽

10.1136/bmjopen-2017-018243 ◽

2017 ◽

Vol 7 (11) ◽

pp. e018243 ◽

Cited By ~ 8

Author(s):

Vera Maria Avaldi ◽

Jacopo Lenzi ◽

Stefano Urbinati ◽

Dario Molinazzi ◽

Carlo Descovich ◽

...

Keyword(s):

Heart Failure ◽

Observational Study ◽

Administrative Data ◽

Hospital Readmission ◽

Patient Adherence ◽

Angiotensin Receptor Blockers ◽

Secondary Outcome ◽

Evidence Based ◽

Aldosterone Antagonists ◽

Β Blockers

ObjectivesTo evaluate the effect of cardiologist care on adherence to evidence-based secondary prevention medications, mortality and readmission within 6 months of discharge in patients with heart failure (HF).DesignRetrospective observational study based on administrative data.SettingLocal Healthcare Authority (LHA) of Bologna, one of the largest LHAs of Italy with ~870 000 inhabitants.ParticipantsAll patients residing in the LHA of Bologna discharged from hospital with a diagnosis of HF between 1 January 2015 and 31 December 2015.Primary and secondary outcome measuresMultivariable regression analysis was used to assess the association of inpatient and outpatient cardiologist care with adherence to evidence-based medications, all-cause mortality and hospital readmission (including emergency room visits) within 6 months of discharge.ResultsThe study population included 2650 patients (mean age 82.3 years). 340 (12.8%) patients were discharged from cardiology wards, while 635 (24.0%) were seen by a cardiologist during follow-up. Inpatient and outpatient cardiologist care was associated with an increased likelihood of adherence to ACE inhibitors/angiotensin receptor blockers (ACEIs/ARBs), β-blockers and aldosterone antagonists after discharge. The risk of mortality was significantly lower among patients adherent to ACEIs/ARBs and/or β-blockers (–53% and –28%, respectively); the risk of hospital readmission was significantly lower among patients adherent to ACEIs/ARBs (–28%).ConclusionsCompared with non-specialist care, cardiologist care improves patient adherence to evidence-based medications and might thus favourably affect mortality and readmission following HF.

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