Many heart failure patients being discharged from hospital without appropriate medications: study

A recent study of Canadians hospitalized for heart failure suggests that many aren’t getting appropriate medications at discharge, even though they are eligible for such therapies. “There is a large gap between what is being prescribed and what the guidelines would recommend we do. There’s a large cohort of patients that are not being treated appropriately,” said Dr. Sean Virani, senior author of the paper, vice-president of the Canadian Cardiovascular Society and head of the division of cardiology at Providence Health Care in Vancouver. Hospitalization represents a key time to intervene in heart failure management and re-optimize patient care, he said. Once patients are out of hospital, there tends to be a lag in when patients are prescribed appropriate heart failure medications, previous studies from Canada and elsewhere suggest. “We know that currently when patients get to the community there’s a really slow uptake of guideline-directed medical therapy, really slow initiation of guideline-directed medical therapy,” Dr. Virani said. “If we rely on things happening in the outpatient setting, it’s not happening, so we need to take that opportunity of hospitalization to make those changes.” The authors examined the Canadian heart failure registry for patients hospitalized for acute heart failure who were discharged from hospital between January 2017 and April 2020. Of the 809 patients, 455 had heart failure with reduced ejection fraction (HFrEF) and 354 had heart failure with preserved ejection fraction (HFpEF). The majority had chronic heart failure while others had a new diagnosis. Of those eligible to receive guideline-developed therapy among HFrEF patients: 19% were not prescribed a beta-blocker 37.9% were not prescribed an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) 93.4% were not prescribed angiotensin receptor-neprilysin inhibitors (ARNIs) 56% were not prescribed mineralocorticoid receptor antagonists (MRAs) The prescription patterns were based on the Canadian Cardiovascular Society’s 2017 guidelines, when ARNIs were only recommended for certain HFrEF patients and SGLT2 inhibitors weren’t yet approved in Canada for heart failure patients. Among patients with HFpEF eligible for MRA therapy, 76.9% were not prescribed MRA therapy. Eligibility for MRA therapy was determined by TOPHAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Agonist) trial criteria. Read: One-stop shop: New Canadian cardiovascular disease guideline pulls together dozens of recommendations The underprescribing of MRAs and ARNIs worried Dr. Virani the most, he said. “The reason both of those are concerning to me is that the data for those drugs have been available for a really long time,” he said. “We’re still not seeing uptake.” Both of these classes of medication, but particularly MRAs, are largely recommended in all ejection fractions, meaning all heart failure patients should be eligible. “To me that suggests a big gap in knowledge, and likely comfort, in prescribing,” he said. Canadian Cardiovascular Society’s guidelines for treatment of HFrEF were reviewed in April 2021. Dr. Virani said the guidelines are a good start for knowledge translation, and will hopefully spark a better uptake of guideline-recommended treatments and, eventually, a decrease in morbidity and mortality. “Guidelines are an important tool but they have to be coupled with knowledge translation activities,” he noted. The Canadian Cardiovascular Society is producing new heart failure guidelines for 2023. Dr. Virani will serve as chair of the guideline committee. “Things are changing that quickly in this field, that the guidelines we wrote last year now even require further refresh,” he said. This does make it difficult for physicians when the guidelines are evolving so rapidly. The speed with which new knowledge is being developed can act as a barrier to implementation because it requires physicians to take a focused look at heart failure, as well as the other disease states they are treating, Dr. Virani said. Read: Major adverse cardiovascular events linked with tofacitinib in treatment of RA Why were the medications underprescribed? For some patients, the lack of prescription was legitimate due to contraindications, such as being on other medications or having renal dysfunction. Yet many patients were still eligible for medications which have been shown to reduce morbidity and mortality in heart failure patients. For example, of the patients with HFrEF, 73.6% were eligible for ARNIs 94.9% were eligible for beta-blockers 84.4% were eligible for MRAs 80.6% were eligible for ACEIs or ARBs The guidelines suggest that new therapies should be added on to existing therapies, but the study results showed some patients weren’t even on initial therapies. “There were a large group of patients who weren’t on baseline therapy, so they became ineligible for initiation of a new therapy,’” Dr. Virani explained. There was a catch-up period of getting patients onto the baseline therapies so they would be eligible for the added therapy. The other reason the medications were not prescribed may have been due to lack of urgency, the authors said. A 2020 study by researchers at the Montreal Heart Institute suggested that gaps in adherence to heart failure guidelines were explained by physiological factors, such as if the patients were frail or had a history of stroke. However, in this study, the authors suggest that system-related limitations or even inertia on the part of the prescriber caused the gap in prescribing guideline-developed medications. To get better uptake of prescribing guideline-developed medications upon hospital discharge,“there needs to be a much greater sense of urgency [and] the recognition of how these patients face a proximate high risk for recurrent worsening of their heart failure, rehospitalization, and death,” said Dr. Gregg Fonarow, interim chief of cardiology at the University of California in Los Angeles to TCTMD. “Just as you would not send a patient out of the hospital after an acute coronary event without antiplatelet therapy, without lipid-lowering therapy, the same mindset is absolutely essential in the patient hospitalized with heart failure.” The paper was published in a recent issue of JACC: Heart Failure. Read: New Canadian guideline for using GLP-1 agonists and SGLT2 inhibitors for cardiorenal risk reduction

Many heart failure patients being discharged from hospital without appropriate medications: study

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