Utilization and Dose Optimization of Angiotensin-Converting Enzyme Inhibitors among Heart Failure Patients in Southwest Ethiopia

Evaluation of the pharmacotherapeutic impact on contractility recovery in patients with newly diagnosed, acute onset dilated cardiomyopathy

In patients with acute onset dilated cardiomyopathy (DCM) an improvement of left ventricular ejection fraction (LVEF) can occur as an effect of complex therapy. The aim of the study was to evaluate a pharmacotherapeutic impact on LVEF recovery in newly diagnosed DCM heart failure (HF) patients. A total of 2436 patients hospitalized due to acute decompensated HF were retrospectively analyzed. Finally, 24 patients with newly diagnosed DCM (51.4 ± 16.3 years, New York Heart Association 2.3 ± 0.7, LVEF 25 ± 10%) were observed (13.4 ± 16.0 months) in terms of the result of complex therapy. Patients were divided according to LVEF improvement on follow-up echocardiography: "recovery group" (LVEF improvement > 5%; n = 13) and "nonrecovery group" (∆LVEF ≤ 5%; n = 11). Evaluation of baseline parameters showed lower LVEF (19 ± 6 vs 31 ± 10%; P = .0048) and lower incidence of arterial hypertension (27% vs 73%; P = .043) in "recovery" group. After follow-up period LVEF was similar in both groups; however, significant LVEF improvement was demonstrated only in the "recovery group" (19 ± 6% to 34 ± 8%; P < .001). Only the "recovery group" showed significant HF symptoms reduction (New York Heart Association class: 2.5 ± 0.7 to 1.6 ± 0.6; P = .003). The "recovery group" had prescribed higher doses of loop diuretic (equivalent dose of furosemidum: 80 ± 38 mg vs 43 ± 24 mg; P = .025). Despite optimal therapy, significant LVEF improvement is observed only in the half of the patients with newly diagnosed DCM with HF with reduced EF. Prescription of higher doses of loop diuretics may have positive effect on the reduction of symptoms in newly diagnosed DCM HF patients. Lack of other risk factors such as arterial hypertension may increase the chance of LVEF recovery.

Angiotensin-Converting Enzyme Inhibitor Dose Optimization and Its Associated Factors at Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar, Ethiopia

INTRODUCTION

Angiotensin-converting enzyme inhibitors dose optimizations (ACEIs) are essential to boost the treatment outcome in heart failure patients (HF) with reduced ejection fraction. Therefore, the main purpose of this study was to evaluate dose optimization and associated factors of ACEIs among HF patients.

METHOD

An institutional-based retrospective study was conducted on 256 study participants from May 20 to August 30, 2020 in ambulatory care clinic at Felege Hiwot Comprehensive Specialized Hospital. A systematic random sampling method was carried out to select study participants. Data were collected from the patient interview and the review of medical records. Epidata and SPSS version 22 were used for data entry and analysis. A bivariate logistic regression analysis was done to determine the association of independent variables with a dose optimization of ACEIs.

RESULTS

The mean age of the subjects in the study was 53.82 years with a standard deviation (SD) of 17.067 and more than half of (60.9%) the patients were unable to read and write. Among participants who were receiving ACEIs, only 30.6% were taking an optimal dose. Age ≥65 years (AOR 5.04 (2.81-12.56)) and a dose of furosemide ≥40 mg (AOR, 2.62 (1.28-16.74)) were significantly associated with the suboptimal dose of ACEIs.

CONCLUSION

Only one-third of patients received the optimum dose of ACEIs. Older age and dose of furosemide greater >40 mg were significantly associated with suboptimal dosing of ACEIs. Therefore, more attention must be given to older patients with HF in order to optimize the dose of ACEIs administered.

Factors associated with non-use and sub-target dosing of medical therapy for heart failure with reduced ejection fraction

In clinical practice, many patients with heart failure with reduced ejection fraction (HFrEF) are either not prescribed guideline-directed medical therapies for which they are eligible or are prescribed therapies at sub-target doses. The objective of this study was to examine the factors associated with not receiving guideline-directed medical therapies or receiving sub-target doses. We conducted a systematic review of articles published between January 2014 and May 2019 that described dosing patterns and factors associated with non-use and sub-target dosing of HFrEF therapies in clinical practice. Thirty-seven studies were included. The percentages of patients reaching target doses for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, sacubitril/valsartan, beta-blockers, and mineralocorticoid receptor antagonists ranged from 4 to 55%, 11 to 87%, 4 to 60%, and 22 to 80%, respectively. Older age and worsening renal function were associated with non-use and sub-target dosing, lower body mass index was commonly associated with non-use, and hyperkalemia and hypotension were commonly associated with sub-target dosing. In conclusion, several common patient characteristics are associated with non-use and sub-target dosing of medical therapy for HFrEF. These high-risk groups are in particular need of further studies to improve implementation of available medications and to define the role of novel therapies.