Potentially Inappropriate Prescriptions in Heart Failure with Reduced Ejection Fraction (PIP-HFrEF)

Effects of sacubitril/valsartan according to polypharmacy status in PARAGON-HF

AIMS

Patients with heart failure (HF) and preserved ejection fraction (HFpEF) have a particularly high prevalence of comorbidities, often necessitating treatment with many medications. The aim of this study was to evaluate the association between polypharmacy status and outcomes in PARAGON-HF.

METHODS AND RESULTS

In this post hoc analysis, baseline medication status was available in 4793 of 4796 patients included in the primary analysis of PARAGON-HF. The effects of sacubitril/valsartan, compared with valsartan, were assessed according to the number of medications at baseline: 683 non-polypharmacy (<5 medications); 2750 polypharmacy (5-9 medications), and 1360 hyper-polypharmacy (≥10 medications). The primary outcome was total HF hospitalizations and cardiovascular deaths. Patients with hyper-polypharmacy were older, had more severe limitations due to HF (worse New York Heart Association class and Kansas City Cardiomyopathy Questionnaire scores), and had greater comorbidity. The non-adjusted risk of the primary outcome was significantly higher in patients taking more medications, and similar trends were seen for HF hospitalization and cardiovascular and all-cause death. The effect of sacubitril/valsartan versus valsartan on the primary outcome from the lowest to highest polypharmacy category was (as a rate ratio): 1.19 (0.76-1.85), 0.94 (0.77-1.15), and 0.77 (0.61-0.96) (pinteraction = 0.16). Treatment-related adverse events were more common in patients in the higher polypharmacy categories but not more common with sacubitril/valsartan, versus valsartan, in any polypharmacy category.

CONCLUSIONS

Polypharmacy is very common in patients with HFpEF, and those with polypharmacy have worse clinical status and a higher rate of non-fatal and fatal outcomes. The benefit of sacubitril/valsartan was not diminished in patients taking a larger number of medications at baseline.

Treatment Patterns, Outcomes, and Persistence to Newly Started Heart Failure Medications in Patients with Worsening Heart Failure: A Cohort Study from the United States and Germany

BACKGROUND

Data are limited regarding guideline-directed medical therapy (GDMT) treatment patterns in patients with worsening heart failure (HF).

METHODS

We used administrative claims databases in Germany and the USA to conduct a retrospective cohort study of patients with worsening HF. Two cohorts of patients with prevalent HF and a HF hospitalization (HFH) from 2016 to 2019, alive at discharge (N = 75,140 USA; N = 47,003 Germany) were identified. Index date was the first HFH during the study period. One-year HF rehospitalization and mortality rates were calculated and a composite endpoint of both outcomes assessed using Kaplan-Meier estimation. We evaluated HF medication patterns in the 6 months before and after the index date. New users of a HF medication (at discharge/after index HFH) were followed for 1 year to evaluate persistence (no treatment gaps > 2 months) RESULTS: One-year HF rehospitalization rates were 36.2% (USA) and 47.7% (Germany). One year mortality rates were 30.0% (USA) and 23.0% (Germany), and the composite endpoint (mortality/HF rehospitalization) was reached in 55.1 % (USA) and 56.6% (Germany). Kaplan-Meier plots showed the risk for the composite endpoint was high in the early post discharge period. Comparison of patterns pre- and postindex HFH showed some increase in use of mineralocorticoid receptor antagonists (MRAs), angiotensin receptor-neprilysin inhibitor (ARNI), and triple therapy; use of angiotensin-converting enzyme (ACE) inhibitor/ angiotensin receptor blocker (ARB) plus beta-blockers remained constant/slightly declined; < 20% patients received triple therapy (ACE inhibitor/ARB plus beta-blocker plus MRA). A third of patients were new users; 1 year persistence rates were often low.

CONCLUSIONS

Morbidity, mortality, and rehospitalization risk is high among patients with worsening HF; uptake and continuation of GDMT is suboptimal.

Definition of Polypharmacy in Heart Failure: A Scoping Review of the Literature

Patients with heart failure (HF) have a high prevalence of polypharmacy, which can lead to drug interactions, cognitive impairment, and medication non-compliance. However, the definition of polypharmacy in these patients is still inconsistent. The aim of this scoping review was to find the most common definition of polypharmacy in HF patients. We conducted a scoping review searching Medline, Embase, CINAHL, and Cochrane using terms including polypharmacy, HF and deprescribing, which resulted in 7,949 articles. Articles without a definition of polypharmacy in HF patients and articles which included patients < 18 years of age were excluded; only 59 articles were included. Of the 59 articles, 49% (n = 29) were retrospective, 20% (n = 12) were prospective, 10% (n = 6) were cross-sectional, and 27% (n = 16) were review articles. Twenty percent (n = 12) of the articles focused on HF with reduced ejection fraction, 10% (n = 6) focused on HF with preserved ejection fraction and 69% (n = 41) articles either focused on both diagnoses or did not clarify the specific type of HF. The most common cutoff for polypharmacy in HF was five medications (59%, n = 35). There was no consensus regarding the inclusion or exclusion of over-the-counter medications, supplements, or vitamins. Some newer studies used a cutoff of 10 medications (14%, n = 8), and this may be a more practical and meaningful definition for HF patients.

Prevalence and clinical implications of polypharmacy and potentially inappropriate medication in elderly patients with heart failure: results of six months' follow-up

OBJECTIVES

To investigate the prevalence of polypharmacy and potentially inappropriate medication (PIM) in elderly patients with heart failure (HF) and their impact on readmission and mortality.

METHODS

We conducted a study of 274 participants aged 60 years or older with HF. The prevalence of polypharmacy (defined as the use of five or more medications) was calculated, and the 2019 American Geriatrics Society Beers criteria were applied to access PIMs. Medications and PIMs were characterized at admission and discharge, and changes in prescriptions during hospitalization were compared. The impact of polypharmacy and PIM on readmission and mortality were investigated.

RESULTS

The median age of this study population was 68 years old. The median number of prescribed drugs was 7 at admission and 10 at discharge. At discharge, 99.27% of all patients were taking five or more drugs. The incidence of composite endpoint and cardiovascular readmission increased with the number of polypharmacy within 6 months. The use of guideline-directed medical therapy reduced the incidence of composite endpoint events and cardiovascular readmission, while the use of non-cardiovascular medications increased the composite endpoint events. The frequency of PIMs was 93.79% at discharge. The incidence of composite endpoint events increased with the number of PIMs. "PIMs in older adults with caution" increased cardiovascular readmission and "PIMs based on kidney function" increased cardiovascular mortality. Several comorbidities were associated with cardiovascular mortality or non-cardiovascular readmission.

CONCLUSIONS

Polypharmacy and PIM were highly prevalent in elderly patients with HF, and their use was associated with an increased risk of composite endpoint events, readmission and mortality. Non-cardiovascular medications, "PIMs in older adults with caution", "PIMs based on kidney function" and several comorbidities were important factors associated with hospital readmission and mortality. Our findings highlight the importance of medication optimization in the management of HF in elderly patients.

A systematic review investigating the role and impact of pharmacist interventions in cardiac rehabilitation

BACKGROUND

Cardiovascular disease (CVD) is a predominant cause of mortality. Pharmacists play an important role in secondary prevention of CVD, however, their role in cardiac rehabilitation is under-reported and services are under-utilised.

AIM

To explore the role of pharmacists in cardiac rehabilitation, the impact of their interventions on patient outcomes, and prospects of future role development.

METHOD

Databases searched were PubMed, Embase, Medline, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO from January 2006 to October 2021. Randomised and non-randomised controlled trials were selected if they assessed the role of pharmacists in cardiac rehabilitation. Cochrane risk of bias tool, Joanna Briggs Institute (JBI) Critical Appraisal Tool for Quasi-Experimental Studies and the National Heart, Lung and Blood Institute (NIH) quality assessment tool, were used to assess quality and a narrative synthesis was conducted.

RESULTS

The search yielded 786 studies, only five met the inclusion criteria. The pharmacist-led interventions included patient education, medication review and reconciliation, and medication adherence encouragement. Four out of the five studies showed that pharmacist-led interventions in cardiac rehabilitation significantly improved patient clinical and non-clinical outcomes. One study showed a statistically significant reduction in low density lipoprotein-cholesterol (LDL-C) levels to optimal target of < 70 mg/dL (80% vs 60%, p = 0.0084). Two studies reported better medication adherence, and two studies showed greater improvement in all domains of health-related quality of life observed in the intervention group.

CONCLUSION

Pharmacist-led interventions in cardiac rehabilitation could lower CVD risk factors and hence recurrence. Although these findings support pharmacists' involvement in cardiac rehabilitation, larger intervention studies are needed to evaluate the feasibility of pharmacist-led interventions and their impact on hospital admissions and mortality risk.

Holistic approach to drug therapy in a patient with heart failure

Heart failure (HF) is a growing global public health problem affecting at least 26 million people worldwide. The evidence-based landscape for HF treatment has changed at a rapid rate over the last 30 years. International guidelines for the management of HF now recommend the use of four pillars in all patients with reduced ejection fraction: angiotensin receptor neprilysin inhibitors or ACE inhibitors, beta blockers, mineralocorticoid receptor antagonists and sodium-glucose co-transporter-2 inhibitors. Beyond the main four pillar therapies, numerous further pharmacological treatments are also available in specific patient subtypes. These armouries of drug therapy are impressive, but where does this leave us with individualised and patient-centred care? This paper reviews the common considerations needed to provide a holistic, tailored and individual approach to drug therapy in a patient with HF with reduced ejection fraction, including shared decision making, initiating and sequencing of HF pharmacotherapy, drug-related considerations, polypharmacy and adherence.

Effects of sociodemographic and socioeconomic factors on stroke development in Lebanese patients with atrial fibrillation: a cross-sectional study

Background: Non-communicable diseases, the major cause of death and disability, are susceptible to modifiable and non-modifiable risk factors. Atrial fibrillation (AF) increases the risk of stroke by 4 to 5 times and can lead to cardiovascular mortality. This study was conducted to assess the effects of different sociodemographic and socioeconomic factors on stroke development in patients with AF.

Methods: A cross-sectional study was conducted between January and June 2018 on patients recruited from Lebanese community pharmacies. The CHA ₂DS ₂-VASc scoring system is utilized as a stroke risk stratification tool in AF patients. Participants with a previous physician diagnosis of AF, documented on medical records, were included in this study. Data was collected through a survey that was distributed to all eligible patients.

Results: A total of 524 patients were enrolled in the study with a mean age (± SD) of 58.75 ± 13.59 years with hypertension (78.4%) being the most predominant disease. The results showed that obesity (Beta=0.61, p-value =0.011), retirement and unemployment compared to employment (Beta=1.44 and 1.44, p-value=0.001 respectively), divorced/widow compared to married (Beta=1.38, p-value =0.001) were significantly associated with higher CHA ₂DS ₂-VASc scores whereas high versus low socio-economic status (Beta=-1.03, p=0.009) and high school education versus primary education level (Beta=-0.49, p-value=0.025) were significantly associated with lower CHA ₂DS ₂-VASc scores.

Conclusions: The study highlights that the CHA ₂DS ₂-VASc score is affected by the presence of various sociodemographic and socioeconomic characteristics in patients with AF. Thus, screening for those factors may predict the progression of cardiovascular disease and may provide an optimal intervention.

Comparison of standard dose with high dose of methylprednisolone in the management of COVID-19 patients admitted in ICU

CONTEXT

The pathological progression in severe Coronavirus Disease 2019 (COVID-19) includes an excessive and unregulated pro-inflammatory cytokine storm. Though the efficacy of corticosteroids like methylprednisolone (MPS) in severe COVID-19 is proven now, its dose and duration are not precise.

AIMS

Our study aimed to compare the effect of a standard dose (SD) of MPS (60-120 mg/day) to a high dose (HD) of MPS (>120 mg/day) on the outcome of hospitalized COVID-19 patients.

SETTINGS AND DESIGN

This study was a cross-sectional study. Patients admitted to AIIMS, Bhopal's intensive care unit (ICU) from July 2020 to March 2021 were enrolled in the study.

METHODS AND MATERIAL

The patient's medical records were extracted from the medical record section of the hospital. The primary endpoint was the all-cause mortality during the hospital stay. The secondary endpoints were the need for mechanical ventilation, the use of vasopressors, the occurrence of acute kidney injury (AKI), and secondary infections.

STATISTICAL ANALYSIS USED

Data were entered in the MS Excel spreadsheet and coded appropriately.

RESULTS

Our data showed that survival, the need for mechanical ventilation, the occurrence of AKI, and secondary bacterial infection are comparable among the two groups with no significant difference. The logistic regression analysis showed that there is a slightly higher risk of death for patients with an acute respiratory distress syndrome (ARDS) receiving HD of corticosteroids compared to SD, though these results were found to be statistically non-significant.

CONCLUSIONS

In hospitalized patients suffering from severe COVID-19 pneumonia, an SD of MPS is as effective as an HD of MPS in terms of reduction in mortality and need for mechanical ventilation.

Effects of sociodemographic and socioeconomic factors on stroke development in Lebanese patients with atrial fibrillation: a cross-sectional study

Background: Non-communicable diseases, the major cause of death and disability, are susceptible to modifiable and non-modifiable risk factors. Atrial fibrillation (AF) increases the risk of stroke by 4-5 times and can lead to cardiovascular mortality. This study was conducted to assess the effects of different sociodemographic factors on stroke development in patients with AF. Methods: A cross-sectional study was conducted between January and June 2018 on patients recruited from Lebanese community pharmacies. The CHA ₂DS ₂-VASc scoring system is utilized as a stroke risk stratification tool in AF patients. Participants with a previous physician diagnosis of AF, documented on medical records, were included in this study. Results: A total of 524 patients were enrolled in the study with a mean age of 58.75 (± SD) ± 13.59 years with hypertension (78.38%) being the most predominant disease. The results showed that obesity (Beta=0.610, p-value =0.011), retirement and unemployment compared to employment (Beta=1.440 and 1.440, p-value=0.001 respectively), divorced/widow compared to married (Beta=1.380, p-value =0.001) were significantly associated with higher CHA ₂DS ₂-VASc scores whereas high versus low socio-economic status (Beta=-1.030, p=0.009) and high school education versus primary education level (Beta=-0.490, p-value=0.025) were significantly associated with lower CHA ₂DS ₂-VASc scores. Conclusions: The study highlights that the CHA ₂DS ₂-VASc score is affected by the presence of various sociodemographic and socioeconomic characteristics in patients with AF. Thus, screening for those factors may predict the progression of cardiovascular disease and may provide an optimal intervention.

Implementing Clinical Decision Support Tools and Pharmacovigilance to Reduce the Use of Potentially Harmful Medications and Health Care Costs in Adults With Heart Failure

Heart failure (HF) is associated with significant morbidity, mortality, compromised quality of life and socioeconomic burden worldwide. This chronic condition is becoming an increasingly important concern given the increased prevalence of HF among aging populations. Significant contributors toward escalating health care costs are emergency room visits and hospitalizations associated with HF. An important strategy to improve health care outcomes and reduce unnecessary costs is to identify and reduce the prescribing of potentially harmful medications (PHMs) among adults with HF. Previous studies in patients with HF found roughly 10–50% of them were prescribed at least one PHM in ambulatory care and inpatient health care settings. This opinion highlights recent findings from studies assessing prevalence of PHMs, associations between PHM prescribing and characteristics, and what can be done to improve patient outcomes and reduce the use of PHMs and associated health care costs in adults with HF.

Therapeutic role of corticosteroids in COVID-19: a systematic review of registered clinical trials

BACKGROUND

In March 2020, the World Health Organization declared the coronavirus disease 2019 as a global pandemic. Though antiviral drugs and antimalarial drugs are considered treatment options for treating coronavirus disease 2019 (COVID-19), no specific antivirals are currently available for its treatment. Efficient use of drug discovery approaches including repurposing or repositioning of drugs used in the treatment of severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV) is considered recently. The widespread application of corticosteroid therapy in COVID-19 should be backed with careful documented pragmatic research of its use in this context.

MAIN BODY

This article aims to analyze various trials registered across the globe providing an overall picture of the use of corticosteroids in the treatment of COVID-19. An extensive search was conducted on the clinical trial registries around the world to identify all the trials reporting information regarding the use of corticosteroids in COVID-19. Our initial search returned 231 trials, out of which 60 trials were finally included in the analysis. Fifty-six studies were interventional trials, and all the trials had clearly defined primary and secondary outcomes of interest, of which only 11 trials had evaluation of respiratory rate as one of their outcomes.

CONCLUSION

Few preliminary trial findings show promising results and recommend the use of methylprednisolone and dexamethasone in the severe form of the disease; however, there is insufficient data to prove its benefits over its risks. Routine use of corticosteroids should be favored only after a better insight is obtained, with the completion of these trials.