Recommended treatment for heart failure often underused

October 20, 2009

Less than one-third of patients hospitalized for heart failure and participating in a quality improvement registry received a guideline-recommended treatment of heart failure, aldosterone antagonist therapy, according to a study in the October 21 issue of JAMA.

Clinical trials have established the benefits of aldosterone antagonist therapy (an agent that opposes the action of the adrenal hormone aldosterone) in patients with heart failure (HF), such that they were designated as "useful and recommended," within the American College of Cardiology/American Heart Association (ACC/AHA) Chronic HF Guidelines. Adoption of aldosterone antagonists for treatment of HF has been mixed, according to background information in the article.

"The Get With The Guidelines-HF (GWTG-HF) program is a national quality improvement program designed to promote adherence to guideline-based recommendations. It is unknown whether participation in a hospital-based quality program may lead to greater frequency of use of aldosterone antagonist therapy for appropriate indications as well as lower use in situations of increased risk," the authors write.

Nancy M. Albert, Ph.D., R.N., of the Cleveland Clinic, Cleveland, and colleagues examined recent aldosterone antagonist use among hospitalized patients with HF, as well as temporal trends and appropriateness of use. The observational analysis included 43,625 patients admitted with HF and discharged home from 241 hospitals participating in the Get With The Guidelines-HF quality improvement registry between 2005-2007.

In total, 12,565 patients (28.8 percent) from 201 hospitals met ACC/AHA management guidelines criteria, and 4,087 eligible patients (32.5 percent) received an aldosterone antagonist at hospital discharge. Treatment increased modestly from 28 percent to 34 percent over the study period. There was also wide variation in aldosterone antagonist use among hospitals (0 percent-90.6 percent).

"Aldosterone antagonist use in eligible patients was associated with younger age, African American race/ethnicity, lower systolic blood pressure, history of implantable cardioverter-defibrillator use, depression, alcohol use, and pacemaker implantation, and with having no history of renal insufficiency," the authors write. Applying certain appropriateness criteria, inappropriate and potentially inappropriate use of aldosterone antagonist therapy was low and did not change over the 3-year study period.

"These data confirm that in the context of a hospital-based performance improvement program, aldosterone antagonist therapy can be used according to guidelines with little inappropriate use. Given the substantial morbidity and mortality risk faced by patients hospitalized with HF and the established efficacy of aldosterone antagonist prescription in HF, a stronger uptake of aldosterone antagonist therapy indicated by evidence-based guidelines may be warranted," the researchers conclude.
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(JAMA. 2009;302[15]:1658-1665. Available pre-embargo to the media at www.jamamedia.org)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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