Adherence and persistence to pharmacotherapy in patients with heart failure: a nationwide cohort study, 2014-2020

Heart failure burden and care among cardiology inpatients: insights from the Hellenic Cardiorenal Morbidity Snapshot (HECMOS) study

PURPOSE

Heart failure (HF) burden and care varies significantly across different countries. We aimed to illustrate the clinical characteristics and HF-related care among cardiology inpatients in Greece.

METHODS

We collected information about all cardiology inpatients on the 3rd of March 2022. The current analysis focuses on acute or chronic HF.

RESULTS

Among a total of 923 participants, 280 (30%) concerned cases of acute HF whereas 351 patients (38%), (median age 79 ± 12 years, male gender 63.8%) had a history of chronic HF, with their majority presenting with multiple comorbidities and previous HF hospitalizations. 173 (49%) of chronic HF participants had reduced LVEF. Ischemic heart disease was the predominant HF etiology (182, 51.9%). Prior to the index admission, chronic HF cases were receiving diuretics, beta blockers, ACEi/ARBs, ARNI, MRAs, and SGLT2i at 79.8%, 74.4%, 43.3%, 10.8%, 40.7%, and 14%, respectively. Independent predictors of lower prescription rates of Guideline Directed Medical Therapy (GDMT) included advanced age (p < 0.001), chronic kidney disease (RASi OR 0.392, p = 0.008, MRA OR 0.523 p = 0.097), and lack of follow-up in dedicated HF clinics (p = 0.006). No regional differences with regards to GDMT were identified.

CONCLUSION

In this nation-wide real-world snapshot study, patients with chronic and acute HF accounted for a significant proportion of cardiology inpatients, while ischemic heart disease was the leading HF cause. GDMT and device therapy can be improved. Follow-up in dedicated HF units was related with increased prescription rates of GDMT, whereas this was not affected by geographical region.

How do doctors address heart failure patients' disclosures of medication adherence problems during hospital and primary care consultations? An exploratory interaction-based observational cohort study

OBJECTIVES

To investigate how doctors and self-managing older patients with heart failure (HF) discuss the patients' potential or ongoing medication adherence problems, and how such discussions evolve as patients transition from hospital to home, with particular focus on: (1) doctors' communicative actions aimed at addressing patient disclosures of adherence problems and (2) patients' feedback indicating whether their doctor's supportive actions were acceptable to them.

DESIGN

Exploratory interaction-based observational cohort study. Inductive microanalysis of authentic patient-doctor consultations, audio recorded for each patient at: (1) first ward visit in hospital, (2) discharge visit from hospital and (3) follow-up visit with general practitioner (GP).

SETTING

Hospital and primary care, Norway (2022-2023).

PARTICIPANTS

25 patients with HF (+65 years) and their attending doctors (23 hospital doctors, 25 GPs).

RESULTS

Analysis of 74 consultations revealed that 25 HF patients disclosed 23 practical adherence problems indicating risks of unintentional non-adherence (eg, limited resources to manage medications) and 39 perceptual problems indicating risks of intentional non-adherence (eg, worries, negative experience or stance). Doctors addressed 79% of patients' disclosures by: (1) exploring the scope of the problem or (2) providing supportive actions to improve patients' ability or motivation to adhere. We calculated nearly five times higher odds for doctors to address patients' practical problems to their perceptual problems (OR 4.79, 95% CI 1.25 to 25.83). Unresolved problems included: (1) doctors addressed patients' disclosures, but patients signalled the supportive actions were unsuitable (37%) and (2) doctors left disclosures unaddressed (21%).

CONCLUSIONS

In this explorative study, the doctors were more likely to address the patients' adherence problems associated with unintentional non-adherence risks than those associated with intentional non-adherence risks. Even when doctors attempted to address HF patients' medication adherence problems, half of the problems remained unresolved, usually because patients indicated that the doctor's suggestion to improve their situation was against their preference.

Contextual Factors Affecting Adherence Revealed by Old Patients with Heart Failure in Hospital and Primary Care Interactions: A Descriptive Study

Introduction

Old patients with heart failure are a vulnerable patient group facing various challenges, specifically during the transition from hospital to home. Non-biomedical factors, or "contextual factors", such as patient attitudes and social support, can influence treatment adherence. However, their role in clinical interactions is not well understood. This study aimed to identify and describe how and when these factors manifest during clinical interactions in the hospital-to-home transition.

Methods

We audio-recorded 42 old patients with heart failure admitted to hospital interacting with their physicians at: 1. the first ward visit, 2. discharge visit, 3. first primary care visit after discharge. Based on an umbrella review, we developed a list of 48 factors known to affect adherence among cardiovascular patients. Patient utterances from the recordings containing information on one of these factors (contextual indicators (CI)) were extracted and categorized according to the type of factor, mentioned impact, and being a facilitator or barrier to adherence.

Results

From the 105 audio recordings, 742 CI were identified, each interaction containing an average of 7 CI (SD = 4.2; median = 6). CI considered to have a potential impact on patient's life or adherence were overall evenly split between facilitators (n = 82, 42%) and barriers (n = 115, 58%), and both types of CI appeared in most patient trajectories. The most salient barrier CI was related to patients' concerns regarding medications side effects and regimen complexity, while CI facilitators were more commonly related to patients' knowledge, motivation and social support.

Discussion

The findings from this study provide insights for clinicians to the main types of non-biomedical factors revealed by old patients with heart failure in medical interactions, which affect their treatment adherence. Clinicians should particularly consider patient concerns regarding medications' side effects and the regimen complexity as important aspects to discuss, leveraging on motivational and social resources if present.

Factors Influencing Medication Adherence in Heart Failure Patients-A Survey Among Cardiac Healthcare Providers

Adhering to medication regimens is key behavior to alleviate symptoms and slow disease progression in heart failure (HF). This study explores cardiac healthcare providers' perceptions and experiences of factors influencing medication adherence (MA) in HF patients, with findings contributing to developing a HF-specific MA assessment scale. Using a cross-sectional, mixed methods design, we conducted an online survey with both closed and open-ended questions distributed to cardiac healthcare providers, working at the National University Hospital in Iceland. The survey consisted of 103 questions divided into 18 themes. Analysis included descriptive statistics of the participants' responses to closed responses with simplified scoring. Free-text responses were grouped into thematic categories and then into subthemes. Of 104 healthcare providers invited, 73 (70%) participated. Key factors identified as most beneficial for supporting MA included supportive patient-provider relationships (97%), selecting suitable drug formulation (96%), healthcare support at home (95%), and multi-dose dispensing from pharmacies (93%). The youngest and oldest HF patients were believed to be at the highest risk of medication non-adherence, particularly among males. Other patients estimated at increased risk included those with alcohol and/or substance abuse (89%), those with limited knowledge of medication effects (89%), those perceiving medication as useless (88%), and those with cognitive impairment (86%). Most participants (73%) agreed that healthcare providers should assess and document MA in clinical care. These findings provide a comprehensive overview of factors that cardiac healthcare providers believe influence non-adherence in HF patients, contributing to the development of a HF-specific MA scale.

Assessing the application of American Heart Association (AHA) guidelines in the management of heart failure with reduced ejection fraction

BACKGROUND

Heart failure (HF) is a significant global health issue. Appropriate and timely treatment at target doses significantly reduces mortality and enhances quality of life. However, studies indicate suboptimal pharmacotherapy among patients. This study aims to assess the medical treatment of patients with heart failure and reduced ejection fraction (HFrEF) and their adherence to the American Heart Association (AHA) guidelines. The study was designed as a cross-sectional analysis in the cardiac department of Razi Hospital in Birjand from March 20, 2020, to March 11, 2023, focusing on patients with left ventricular ejection fraction less than or equal to 40%. Data were extracted from patients' medical records. Medications were classified according to the four-pillar therapy recommended by the AHA, including β-blockers, ARNI, ACE inhibitors/ARBs, SGLT2, and MRAs. Patients were grouped based on their treatment regimens. The percentage of achieved target doses for each medication was categorized as follows: 0-25%, 25-50%, 50-99%, and 100%. Statistical analysis was conducted using SPSS version 22.

RESULTS

The study included patients with a mean age of 66 ± 13.7 years, of whom 278 (69%) were male. The mean ejection fraction was 26.8 ± 9.6%, and the most prevalent comorbidity was coronary artery disease (CAD) observed in 68.0% of patients. The in-hospital mortality rate was 5%. The results revealed that only 20% were on quadruple therapy, while 10% received none of the recommended medications. The prescription rates for key medications were as follows: β-blockers 76.4%, ACE inhibitors/ARBs 71.6%, MRA 63.3%, SGLT2I 33.5%, and ARNI 0%. Notably, 94.8% of prescribed SGLT2I doses met the target dose, while 84.4% of β-blocker prescriptions and 61.8% of ACEI/ARB prescriptions were below 75% of the target dose.

CONCLUSION

The findings reveal significant gaps in the prescription of essential therapies, including MRAs and ARNIs, which are crucial for managing myocardial dysfunction. Addressing these gaps underscores the necessity for ongoing education and training for healthcare providers in heart failure management.

Sacubitril/valsartan in a wide spectrum of heart failure patients (from mechanisms of action to outcomes in specific populations)

Heart failure (HF) represents a significant global health challenge, characterized by high morbidity and mortality rates, decreased quality of life and a significant financial and economic burden. The prevalence of HF continues to rise, driven by an ageing population and an increasing burden of comorbidities such as hypertension, diabetes and obesity. Understanding the complex pathophysiology and developing effective treatments are critical for improving patient outcomes, yet the range of effective, life-prolonging medication classes has remained mostly constant in the last few decades. The introduction of angiotensin receptor neprilysin inhibitors (ARNI) was a major breakthrough in HF management, for the first time targeting the natriuretic peptide system in addition to the renin-angiotensin-aldosterone pathway to potentiate the effects of older drug classes. ARNI shows superiority in clinical outcomes compared to previous guideline-directed therapies, especially in patients with reduced ejection fraction (EF). It has now been implemented into international guidelines, endorsing its use in patients with HF and reduced ejection fraction (HFrEF) and HF with mildly reduced ejection fraction (HFmrEF). This review summarises the mechanism of action of Sac/Val, presents key clinical trials in a range of patient populations and HF aetiologies and outlines gaps in knowledge and potential novel uses of Sac/Val.

Therapeutic appraisal in protracted heart failure

Data from pivotal randomized controlled trials established the four pillars of guideline-directed medical therapy in heart failure with reduced ejection fraction. The randomized controlled trials enrolled stable patients with New York Heart Association functional class II-III and a low incidence of cardiovascular death and hospitalization for heart failure. Whether the four pillars retain therapeutic value when a patient's symptoms worsen and life expectancy decreases has received scarce attention. We review the observational studies that point to the fading benefit of neurohormonal modulation and cardiac afterload reduction in the late stages of cardiovascular or renal diseases. We then propose a pragmatic approach for collecting evidence-based data on sequential withdrawal of the four pillars in patients with heart failure and reduced ejection fraction after years of guideline-directed medical therapy.

High-intensity care for GDMT titration

Heart failure (HF) is a systemic disease associated with a high risk of morbidity, mortality, increased risk of hospitalizations, and low quality of life. Therefore, effective, systemic treatment strategies are necessary to mitigate these risks. In this manuscript, we emphasize the concept of high-intensity care to optimize guideline-directed medical therapy (GDMT) in HF patients. The document highlights the importance of achieving optimal recommended doses of GDMT medications, including beta-blockers, renin-angiotensin-aldosterone inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter inhibitors to improve patient outcomes, achieve effective, sustainable decongestion, and improve patient quality of life. The document also discusses potential obstacles to GDMT optimization, such as clinical inertia, physiological limitations, comorbidities, non-adherence, and frailty. Lastly, it also attempts to provide possible future scenarios of high-intensive care that could improve patient outcomes.

Analysis of Longitudinal Patterns and Predictors of Medicine Use in Residential Aged Care Using Group-Based Trajectory Modeling: The "MEDTRAC-Cardiovascular" Longitudinal Cohort Study

AIM

Cardiovascular diseases are the leading cause of death globally. Ensuring ongoing use of medicines-medication persistence-is crucial, yet no prior studies have examined this in residential aged care facilities (RACFs). We aimed to identify long-term trajectories of persistence with cardiovascular medicines and determine predictors of persistence trajectories.

METHOD

A longitudinal cohort study of 2837 newly admitted permanent residents from 30 RACFs in New South Wales, Australia. We monitored weekly exposure to six cardiovascular medicine classes-lipid modifiers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARBs), beta-blockers, diuretics, calcium channel blockers (CCB), and cardiac therapy-over 3 years. Group-based trajectory modeling was employed to determine persistence trajectories for each class.

RESULTS

At baseline, 76.6% (n = 2172) received at least one cardiovascular medicine with 41.2% receiving lipid modifiers, 31.4% ACEI/ARBs, 30.2% beta-blockers, 24.4% diuretics, 18.7% CCBs, and 14.8% cardiac therapy. The model identified two persistence trajectories for CCBs and three trajectories for all other classes. Sustained high persistence rates ranged from 68.4% (ACEI/ARBs) to 79.8% (beta-blockers) while early decline in persistence and subsequent discontinuation rates ranged from 7.6% (cardiac therapy) to 25.3% (CCBs). Logistic regressions identified 11 predictors of a declining persistence across the six medicine classes.

CONCLUSION

Our study revealed varied patterns of cardiovascular medicine use in RACFs, with 2-3 distinctive medicine use trajectories across different classes, each exhibiting a unique clinical profile, and up to a quarter of residents discontinuing a medicine class. Future studies should explore the underlying reasons and appropriateness of nonpersistence to aid in identifying areas for improvement.

Mineralocorticoid receptor antagonists in heart failure with reduced ejection fraction: a systematic review and network meta-analysis of 32 randomized trials

INTRODUCTION

Several randomized controlled trials (RCTs) have examined mineralocorticoid receptor antagonists (MRAs) in heart failure (HF) with reduced ejection fraction (HFrEF). This systematic review and network meta-analysis (NMA) evaluated the comparative efficacy and safety of MRAs in HFrEF.

MATERIALS AND METHODS

MEDLINE(Pubmed), Scopus, Cochrane and ClinicalTrials.gov were searched until April 8, 2024 for RCTs examining the efficacy and/or safety of MRAs in HFrEF. Double-independent study selection, extraction and quality assessment were performed. Random-effects frequentist NMA models were used. Evidence certainty was assessed via Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Totally, 32 RCTs (15685 patients) were analyzed. Eplerenone ranked above spironolactone in all-cause mortality (hazard ratio {HR}=0.78, 95% confidence interval {CI} [0.66,0.91], GRADE:"Moderate"), cardiovascular death (HR=0.74, 95%CI [0.53, 1.04], GRADE:"Low") and in all safety outcomes. Spironolactone was superior to eplerenone in the composite of cardiovascular death or hospitalization (HR=0.67, 95%CI [0.50,0.89], GRADE:"Moderate"), HF hospitalization (HR=0.61, 95%CI [0.43,0.86], GRADE:"Moderate"), all-cause hospitalization (HR=0.51, 95%CI [0.26,0.98], GRADE:"Moderate") and cardiovascular hospitalization (HR=0.56, 95%CI [0.37,0.84], GRADE:"Moderate"). Canrenone ranked first in all-cause mortality, the composite outcome and HF hospitalization. Finerenone ranked first in hyperkalemia (risk ratio [RR]=1.56, 95%CI [0.89,2.74], GRADE:"Moderate"), renal injury (RR=0.56, 95%CI [0.24,1.29]), any adverse event (RR=0.84, 95%CI [0.75,0.94], GRADE:"Moderate"), treatment discontinuation (RR=0.89, 95%CI [0.64,1.23]) and hypotension (RR=1.06, 95%CI [0.12,9.41]).

CONCLUSIONS

MRAs are effective in HFrEF with certain safety disparities. Spironolactone and eplerenone exhibited similar efficacy, however, eplerenone demonstrated superior safety. Finerenone was the safest MRA, while canrenone exhibited considerable efficacy, nonetheless, evidence for these MRAs were scarce.

Medication adherence, related factors and outcomes among patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension: a systematic review

INTRODUCTION

Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are life-threatening conditions that can progress to death without treatment. Although strong medication adherence (MA) is known to enhance outcomes in chronic illnesses, its association with PAH and CTEPH was sporadically explored. This study aims to examine the MA of patients with PAH or CTEPH, identify factors associated with low adherence and explore the resulting outcomes.

METHODS

A systematic review was conducted by searching multiple databases (Medline, Embase, Cochrane Central, ClinicalTrials.gov, Scopus, Web of Science and Google Scholar) from 6 March 1998 to 6 July 2023. We included studies reporting MA as primary or secondary end-points. Study selection, data extraction and methodological quality assessment were performed in duplicate.

RESULTS

20 studies involving 22 675 patients met the inclusion criteria. Heterogeneity was observed, particularly in the methods employed. MA means ranged from 0.62 to 0.96, with the proportion of patients exhibiting high MA varying from 40% (95% CI 35-45%) to 94% (95% CI 88-97%). Factors associated with low adherence included increased treatment frequency, time since diagnosis and co-payment. High MA seems to be associated with reduced hospitalisation rates, inpatient stays, outpatient visits and healthcare costs.

CONCLUSIONS

This systematic review underscores the heterogeneity of MA across studies. Nevertheless, the findings suggest that high MA could improve patients' clinical outcomes and alleviate the economic burden. Identifying factors consistently associated with poor MA could strengthen educational efforts for these patients, ultimately contributing to improved outcomes.

Real-world characteristics and use patterns of patients treated with vericiguat: A nationwide longitudinal cohort study in Germany

PURPOSE

Vericiguat reduced clinical endpoints in patients experiencing worsening heart failure in clinical trials, but its implementation outside trials is unclear.

METHODS

This retrospective analysis of longitudinally collected data was based on the IQVIA™ LRx database, which includes ~ 80% of the prescriptions of the 73 million people covered by the German statutory health insurance.

RESULTS

Between September 2021 and December 2022, vericiguat was initiated in 2916 adult patients. Their mean age was 73 ± 13 years and 28% were women. While approximately 70% were uptitrated beyond 2.5 mg, only 36% reached 10 mg. Median time to up-titration from 2.5 mg to 5 mg was 17 (quartiles: 11-33) days, and from 2.5 to 10 mg 37 (25-64) days, respectively. In 87% of the patients, adherence to vericiguat was high as indicated by a medication possession ratio of  ≥ 80%, and 67% of the patients persistently used vericiguat during the first year. Women and older patients reached the maximal dose of 10 mg vericiguat less often and received other substance classes of guideline-recommended therapy (GDMT) less frequently. The proportion of patients receiving four pillars of GDMT increased from 29% before vericiguat initiation to 44% afterwards.

CONCLUSION

In a real-world setting, despite higher age than in clinical trials, adherence and persistence of vericiguat appeared satisfactory across age categories. Initiation of vericiguat was associated with intensification of concomitant GDMT. Nevertheless, barriers to vericiguat up-titration and implementation of other GDMT, applying in particular to women and elderly patients, need to be investigated further.

Prognostic Impact of Reduced Left Ventricular Ejection Fraction After Endovascular Therapy for Lower Extremities

BACKGROUND

The mechanism underlying a poor prognosis in patients with lower-extremity artery disease (LEAD) with heart failure is unknown. We examined the prognostic impact of the left ventricular ejection fraction (LVEF) in patients with LEAD who underwent endovascular therapy (EVT).

METHODS AND RESULTS

From August 2014 to August 2016, 2,180 patients with LEAD (mean age, 73.2 years; male, 71.9%) underwent EVT and were stratified into low-LVEF (LVEF <40%; n=234, 10.7%) and not-low LVEF groups. In the low- vs. not-low LVEF groups, there was a higher prevalence of heart failure (i.e., history of heart failure hospitalization or New York Heart Association functional class III or IV symptoms) (44.0% vs. 8.3%, respectively), diabetes mellitus, chronic kidney disease, below-the-knee lesion, critical limb ischemia, and incidence of major cardiovascular and cerebrovascular events (MACCEs) and major adverse limb events (MALEs) (P<0.001, all). Low LVEF independently predicted MACCEs (hazard ratio: 2.23, 95% confidence interval: 1.63-3.03; P<0.001) and MALEs (hazard ratio: 1.85, 95% confidence interval: 1.15-2.96; P=0.011), regardless of heart failure (P value for interaction: MACCEs: 0.27; MALEs: 0.52).

CONCLUSIONS

Low LVEF, but not symptomatic heart failure, increased the incidence of MACCEs and MALEs. Intensive cardiac dysfunction management may improve LEAD prognosis after EVT.

Guideline implementation, drug sequencing, and quality of care in heart failure: design and rationale of TITRATE-HF

AIMS

Current heart failure (HF) guidelines recommend to prescribe four drug classes in patients with HF with reduced ejection fraction (HFrEF). A clear challenge exists to adequately implement guideline-directed medical therapy (GDMT) regarding the sequencing of drugs and timely reaching target dose. It is largely unknown how the paradigm shift from a serial and sequential approach for drug therapy to early parallel application of the four drug classes will be executed in daily clinical practice, as well as the reason clinicians may not adhere to new guidelines. We present the design and rationale for the real-world TITRATE-HF study, which aims to assess sequencing strategies for GDMT initiation, dose titration patterns (order and speed), intolerance for GDMT, barriers for implementation, and long-term outcomes in patients with de novo, chronic, and worsening HF.

METHODS AND RESULTS

A total of 4000 patients with HFrEF, HF with mildly reduced ejection fraction, and HF with improved ejection fraction will be enrolled in >40 Dutch centres with a follow-up of at least 3 years. Data collection will include demographics, physical examination and vital parameters, electrocardiogram, laboratory measurements, echocardiogram, medication, and quality of life. Detailed information on titration steps will be collected for the four GDMT drug classes. Information will include date, primary reason for change, and potential intolerances. The primary clinical endpoints are HF-related hospitalizations, HF-related urgent visits with a need for intravenous diuretics, all-cause mortality, and cardiovascular mortality.

CONCLUSIONS

TITRATE-HF is a real-world multicentre longitudinal registry that will provide unique information on contemporary GDMT implementation, sequencing strategies (order and speed), and prognosis in de novo, worsening, and chronic HF patients.

Frailty, health literacy and self-care in patients admitted with acute heart failure

BACKGROUND

There is limited knowledge from Norway on clinical characteristics, self-care and health literacy in patients admitted to hospital with acute heart failure. Our aim was to identify these factors in this group.

MATERIAL AND METHOD

We included patients admitted with acute heart failure over a period of six months (2022/2023) at Drammen Hospital and Vestfold Hospital Trust. Cardiac nurses collected information from the patients, including self-assessed knowledge on an ordinal scale from 0 (little knowledge) to 10 (good knowledge). Clinical frailty scores were calculated and data from the hospital records were recorded.

RESULTS

Of 136 patients with acute heart failure, 81 were included. Median age was 79 (range 35-95) years, 35 (43 %) were women. A total of 35 (43 %) had been admitted with heart failure exacerbation in the past year. The patients had a median of 5 (1-10) diagnoses, and the median score on the clinical frailty scale was 4 (1-7), corresponding to 'vulnerable'. A total of 63 (78 %) had been diagnosed with heart failure before admission to hospital. Of these, 13 (21 %) were unaware of the diagnosis, and their self-assessed knowledge was median 3 (25th and 75th percentile, 0-5) for management of heart failure, 2 (25th and 75th percentile, 0-5) for lifestyle interventions and 0 (25th and 75th percentile, 0-2) for heart medications. Altogether 42 out of 63 (67 %) weighed themselves weekly, 13 (21 %) measured their blood pressure, while 3 (5 %) had a self-care plan. Of 50 patients with left ventricle ejection fraction ≤ 40 %, 32 (64 %) were discharged with betablockers and angiotensin II receptor blockers or a combination drug with a neprilysin inhibitor, whereas 11 (22 %) were also prescribed SGLT2 inhibitors and mineralocorticoid receptor antagonists.

INTERPRETATION

The included patients were multimorbid and had a low level of self-care and health literacy. There is potential to optimise well-documented medicinal treatment.