Patients with heart failure are often older and have a variety of chronic conditions, such as diabetes, atrial fibrillation, coronary disease, high blood pressure or cognitive dysfunction, requiring multiple medications. “They may be on up to 22 medications to treat heart failure and comorbidities,” says Nancy Albert, PhD, CCNS, CHFN, CCRN, NE-BC, FAAN, Associate Chief Nursing Officer of Nursing Research and Innovation at Cleveland Clinic.
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Do healthcare providers who prescribe core medications for heart failure with reduced ejection fraction (HFrEF; also known as systolic heart failure) use them based on national heart failure guidelines? Albert’s interest in answering this question was sparked when she served on a national steering committee for a study titled Change the Management of Patients with Heart Failure (CHAMP-HF), which compared the use of four classes of medication therapies over time: angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARB), angiotensin receptor neprilysin inhibitors (ARNI), beta-blockers (βB) and mineralocorticoid receptor antagonists (MRA).
“CHAMP-HF followed nearly 5,000 patients enrolled in 152 sites. During the study period, we received pragmatic information about prescribing practices, including medication use, dose and titration over time as part of patients’ lived experiences with HFrEF,” says Albert. “One of my programs of research is on medication optimization in HFrEF, and I wanted to learn more about core heart failure medication use and dosage in patients with and without specific comorbidities.”
Albert served as principal investigator on a sub-study that examined variation in use and dosing of ACEi, ARB, ARNI, MRA and βB in patients with HFrEF and comorbidities (atrial fibrillation, asthma/chronic obstructive pulmonary disease, obstructive sleep apnea and depression). The study was published in the May 2021 issue of the American Heart Journal.
Results of the study
Approximately 38% of the patients had one comorbidity and 73 of 4,815 patients had all four.
Study results were extensive, considering patients without comorbidities and with each of the four conditions and four medication therapy classes.
“In examination of the univariate data – without controlling for patient characteristics independently associated with outcomes – we learned that patients with any of the four comorbid conditions were less likely to receive a core HFrEF medication known to be important in improving HFrEF morbidity and mortality,” says Albert.
After adjusting for patient characteristics in multivariable modeling, a few key results were:
- Patients with atrial fibrillation were 18% less likely to be on an ACEi or ARB.
- Patients with obstructive sleep apnea were 26% less likely to be on an ACEi or ARB, but 25% more likely to be on an ARNI and 31% more likely to be on an MRA.
- Of patients with depression, the odds of being on target dose of ACEi or ARB medications was 32% lower than among patients without depression.
“The most significant findings were found in patients with obstructive sleep apnea,” says Albert. “In general, providers were more likely to use renin-angiotensin system medications in patients with obstructive sleep apnea, possibly because obstructive sleep apnea is associated with hypertension, coronary artery disease and other cardiac conditions, for all of which renin angiotensin system inhibitors are indicated. Thus, providers may have found it easier to make medication decisions. In HFrEF, prescription and uptitration of ACEi/ARB or ARNI, βB and MRA are important regardless of high blood pressure and other cardiac conditions.”
Implications on clinical practice
Overall, providers failed to use FDA-approved and national guideline-supported medications to treat HFrEF after accounting for patient contraindications.
“Findings reinforce the need for greater provider and clinician education and clinical decision support tools that aide in prescribing and escalating dosing of HFrEF guideline-directed medication therapies and also quality monitoring of ambulatory cardiology practices,” says Albert.