1
|
Georgiopoulou VV, Kalogeropoulos AP, Giamouzis G, Agha SA, Rashad MA, Waheed S, Laskar S, Smith AL, Butler J. Digoxin therapy does not improve outcomes in patients with advanced heart failure on contemporary medical therapy. Circ Heart Fail 2009; 2:90-7. [PMID: 19808323 DOI: 10.1161/circheartfailure.108.807032] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND The impact of digoxin on outcomes of patients with advanced heart failure (HF) receiving optimal contemporary therapy is not known. METHODS AND RESULTS We retrospectively reviewed data of 455 advanced HF patients referred for transplant evaluation (age, 52+/-12 years; ejection fraction, 18.3+/-8%); 227 (49.9%) were on digoxin at baseline. Primary outcome was death (n=101), urgent transplantation (n=14), or ventricular assist device implantation (n=4); secondary outcomes included HF and all-cause hospitalizations. Digoxin use was evaluated (1) in the original cohort; (2) in a propensity score-matched subset (n=322); (3) as a time-dependent covariate; and (4) after adjustment for Seattle Heart Failure Score. Patients were on optimal therapy: angiotensin-II modulation, 92.5%; beta-blockers, 91.2%; aldosterone antagonists, 45.6%; and devices, 71.0%. After a median of 27 months, 83 of 277 (36.6%) patients treated with digoxin versus 36 of 228 (15.8%) patients without digoxin met primary outcome (hazard ratio [HR], 2.28; 95% CI, 1.51 to 3.43; P<0.001). This risk persisted in the matched subset (HR, 1.73; 95% CI, 1.09 to 2.75; P=0.021) and with time-varying digoxin use (HR, 2.05; 95% CI, 1.23 to 3.41; P=0.011). Digoxin was associated with higher risk among patients in sinus rhythm compared with atrial fibrillation. Digoxin was not associated with improvement in either all-cause or HF hospitalization rates. These results were similar across sex and race and when adjusted for Seattle Heart Failure Score and renal function. CONCLUSIONS This study suggests that digoxin therapy may be of no benefit in patients with advanced HF referred for cardiac transplantation who received optimal medical therapy. Treatment with digoxin should be used cautiously in such patients because of risk for adverse outcomes.
Collapse
|
2
|
Gupta R, Tang WHW, Young JB. Patterns of beta-blocker utilization in patients with chronic heart failure: experience from a specialized outpatient heart failure clinic. Am Heart J 2004; 147:79-83. [PMID: 14691423 DOI: 10.1016/j.ahj.2003.07.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Beta-blockers have been shown incontrovertibly to improve morbidity and survival in patients with heart failure. However, there is limited information regarding their use in clinical practice settings, and reasonable utilization targets for quality improvement initiatives have not been established. METHOD We identified 500 consecutive patients with chronic heart failure seen at a specialized outpatient heart failure clinic from March 2001 to May 2001, and retrospectively extracted clinical and drug information from an electronic medical record. RESULTS In this cross-sectional analysis, the rate of beta-blocker utilization was 69%. Seventy-five percent of patients had at least tried a beta-blocker. Among those with beta-blockers initiated, 16% experienced side effects that led to drug discontinuation (9.1%) or down-titration (6.9%) that was similar across all NYHA classes. A lower utilization rate of beta-blockers was observed in patients of advanced age and those with diabetes mellitus, concomitant antiarrhythmic therapy, and preserved left ventricular ejection fraction (P <.05). Respiratory disease remained the most common reason for withholding beta-blocker therapy, especially with severe obstructive (rather than restrictive) physiology. CONCLUSION It appears that about 70% of patients with chronic heart failure can be successfully treated with a beta-blocker in a specialized heart failure outpatient setting where physicians are committed to beta-blocker use in heart failure. It is possible that subgroups with lower utilization rates can be targeted for quality improvement initiatives.
Collapse
Affiliation(s)
- Ritesh Gupta
- Department of Internal Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
| | | | | |
Collapse
|
3
|
Grancelli H, Varini S, Ferrante D, Schwartzman R, Zambrano C, Soifer S, Nul D, Doval H. Randomized Trial of Telephone Intervention in Chronic Heart Failure (DIAL): study design and preliminary observations. J Card Fail 2003; 9:172-9. [PMID: 12815566 DOI: 10.1054/jcaf.2003.33] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND In the last few years different approaches based on comprehensive patient care and close surveillance by multidisciplinary teams have shown promising results in heart failure. However, current evidence mainly derives from small and often nonrandomized studies performed at a single center, with selected populations, using dissimilar and complex strategies. We designed a large randomized study to test the hypothesis that a single program, based on a centralized telephone intervention performed by trained nurses, could reduce morbidity and mortality in chronic heart failure. METHODS The Randomized Trial of Telephone Intervention in Chronic Heart Failure (DIAL) is a randomized, controlled, open trial designed to compare frequent telephone follow-up intervention versus control. We enrolled 1518 patients with stable chronic heart failure and optimal treatment from 51 centers in Argentina. DIAL trial intervention strategy is based on frequent telephone follow-up provided by nurses trained in heart failure and performed from a single surveillance center, assuring a homogeneous and high quality intervention. The primary objective is to determine the effect of the intervention as compared with the usual follow-up on the combined endpoint of all-cause mortality or hospitalization for worsening heart failure. The objectives of the intervention are education, counseling, and monitoring to enhance self-control mechanisms, timely medical visits, diet, and drug therapy compliance. Telephone call frequency was determined according to preestablished criteria of clinical status severity assessed at each phone contact. The study ended in August 2002. CONCLUSION The results of this study may provide information about mortality, hospitalizations, and quality of life contributing to set standards for management programs in the current treatment of chronic heart failure.
Collapse
|
4
|
|
5
|
Antonelli Incalzi R, Pedone C, Pahor M, Onder G, Carbonin PU. Trends in prescribing ACE-inhibitors for congestive heart failure in elderly people. Aging Clin Exp Res 2002; 14:516-21. [PMID: 12674493 DOI: 10.1007/bf03327353] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND AIMS The aim of this study was to analyze trends in the use of ACE-inhibitors in patients aged 65 and older with congestive heart failure (CHF) in the period from 1988 to 1998. METHODS We studied 2985 patients (mean age 79.7 +/- 7 years), hospitalized for CHF in 12 different bimonthly periods. Home therapy prior to hospitalization was assessed retrospectively, and data on in-hospital therapy and discharge prescriptions were collected prospectively. RESULTS Diuretics and digitalis were the most commonly used and prescribed drugs. The use of ACE-inhibitors between 1988 and 1998 increased from 13.4 to 46.7% prior to hospitalization, and from 25.8 to 59.2% as a discharge prescription. The most important factors associated with a prescription of ACE-inhibitors at discharge were previous use (OR 4.35, 95% CI=3.65-5.19), hypertension (OR 1.76, 95% CI=1.47-2.11), valvular heart diseases (OR 2.06, 95% CI=1.51-2.81) and diabetes (OR 1.58, 95% CI=1.29-1.93). Physical impairment was associated with a decreased use of ACE-inhibitors at discharge (OR 0.55, 95% CI=0.45-0.67). CONCLUSIONS The use of ACE-inhibitors for the treatment of CHF progressively increased both at home and in hospital wards of general medicine and geriatrics in the 10-year period studied. Nevertheless, digitalis and diuretics continue to be the most commonly prescribed drugs. A widespread educational effort is needed to increase physicians' awareness of the rationale for prescribing ACE-inhibitors for CHF patients.
Collapse
|
6
|
Abstract
Antagonism of adverse neuro-endocrine responses is the current paradigm by which chronic congestive cardiac failure is treated. Several recent large-scale randomized, controlled trials have confirmed the benefits of beta-adrenergic blocking agents in this regard. In light of the present heart failure 'epidemic', appropriate organization of services is mandatory to ensure that as many patients as possible can benefit from this life-saving therapy.
Collapse
Affiliation(s)
- Niall G. Mahon
- Department of Cardiological Sciences, St George's Hospital Medical School, Cranmer Terrace, SW17 0RE, London, UK
| | | | | |
Collapse
|
7
|
Abstract
In the management of chronic heart failure, polypharmacy is common, necessary, and often overlooked. The increasing costs of care, noncompliance, and frequent adverse drug interactions have led to diminishing benefits by simply adding additional drugs to the already complex regimen. This review outlines a rational pharmacotherapeutic protocol based on establishing overall therapeutic goals and confirming treatment targets, tailoring therapy to individual patients by balancing beneficial and adverse drug effects, and paying particular attention to patient education and other nonpharmacologic support.
Collapse
Affiliation(s)
- W H Tang
- Department of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | |
Collapse
|
8
|
Milfred-LaForest SK. Pharmacotherapy of systolic heart failure: a review of recent literature and practical applications. J Cardiovasc Nurs 2000; 14:57-75. [PMID: 10902104 DOI: 10.1097/00005082-200007000-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Since the publication of the Agency for Health Care Policy and Research Guidelines for treatment of heart failure, a number of new agents have been investigated for this indication. beta-Blockers have now been shown to improve outcomes in mild to moderate heart failure when added to standard therapy. Angiotensin II receptor antagonists have also been investigated and show promise. In general, calcium channel blockers are second- or third-line agents in patients refractory to other therapy. Investigational agents including spironolactone may also hold promise for future therapy.
Collapse
|
9
|
van Kraaij DJ, Jansen RW, Bouwels LH, Gribnau FW, Hoefnagels WH. Furosemide withdrawal in elderly heart failure patients with preserved left ventricular systolic function. Am J Cardiol 2000; 85:1461-6. [PMID: 10856393 DOI: 10.1016/s0002-9149(00)00795-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
To explore the possibilities of furosemide withdrawal in elderly heart failure (HF) patients with intact left ventricular (LV) systolic function and assess its effects on functional status and orthostatic blood pressure homeostasis, we performed a placebo-controlled pilot trial of furosemide withdrawal with 3 months of follow-up in 32 HF patients (aged 75.1 +/- 0.7 years [mean +/- SEM]) with a LV ejection fraction of 60 +/- 2% and without overt congestion. Investigations included repeated clinical assessment, spirometry, standardized 6-minute walking test, and chest x-rays. Measurements of blood pressure response on active standing and Doppler echocardiography were performed before and 3 months after furosemide withdrawal. Recurrent congestive HF occurred in 2 of 21 patients (10%) who discontinued furosemide use, and in 1 of 11 patients (9%) who continued furosemide (p = NS). Three patients restarted furosemide for ankle edema and 1 for blood pressure levels >180/100 mm Hg. After 3 months, there were no differences regarding HF symptom scores, blood pressure, heart rate, spirometric results, 6-minute walking distance, or quality of life scores between patients who discontinued use and patients who continued the therapy. In patients successfully withdrawn, Doppler E/A ratio increased from 0.68 +/- 0.05 to 0.79 +/- 0.06 after withdrawal (p <0.01), and maximum blood pressure decrease on active standing changed from -8 +/- 5 mm Hg to +5 +/- 3 mm Hg systolic (p <0.05). Thus, in this pilot investigation of furosemide withdrawal in elderly HF patients without overt congestion and with a normal LV systolic function, withdrawal was successful in almost all patients and was associated with improvement of LV diastolic filling and blood pressure homeostasis on active standing.
Collapse
Affiliation(s)
- D J van Kraaij
- Department of Geriatric Medicine, University Hospital, Nijmegen, The Netherlands
| | | | | | | | | |
Collapse
|
10
|
van Kraaij DJ, Jansen RW, Gribnau FW, Hoefnagels WH. Diuretic therapy in elderly heart failure patients with and without left ventricular systolic dysfunction. Drugs Aging 2000; 16:289-300. [PMID: 10874524 DOI: 10.2165/00002512-200016040-00005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Long term prescription of diuretics for heart failure is very prevalent among elderly patients, although the rationale for such a treatment strategy is often unclear, as diuretics are not indicated if volume overload is absent. The concept of diastolic heart failure in the elderly might particularly change the role of diuretic therapy, since diuretics may have additional adverse effects in these patients. This paper reviews the effects of diuretic therapy in elderly patients with heart failure, emphasising the differences between patients with normal and decreased left ventricular systolic function. Studies on diuretic withdrawal in elderly patients with heart failure are discussed, with emphasis on issues involved in decision making such as diuretic dose reduction and withdrawal in elderly patients and factors that have been established to predict successful withdrawal. Existing guidelines on the prescription of diuretics in elderly patients with heart failure with normal and decreased left ventricular systolic function and in those with diastolic heart failure are also discussed. By reducing intravascular volume, diuretics may further impair ventricular diastolic filling in patients with diastolic heart failure and thus reduce stroke volume. Indeed, preliminary studies demonstrate that diuretics may provoke or aggravate hypotension on standing and after meals in these patients. Therefore, it is suggested that elderly patients with heart failure with intact left ventricular systolic function should not receive long term diuretic therapy, unless proven necessary to treat or prevent congestive heart failure. This implies that physicians should carefully evaluate the opportunities for diuretic dose tapering or withdrawal in all of these patients, and that a cautiously guided intermittent diuretic treatment modality may be critical in the care for older patients with heart failure with intact left ventricular systolic function.
Collapse
Affiliation(s)
- D J van Kraaij
- Department of Geriatric Medicine, University Hospital Nijmegen, The Netherlands.
| | | | | | | |
Collapse
|
11
|
Abstract
Although the beneficial effects of angiotensin-converting enzyme (ACE) inhibitors in patients with ventricular systolic dysfunction are well documented, historically, a large proportion of patients have not received optimal therapy. Published studies to describe the trends in ACE inhibitor utilization and determinants of their use were reviewed. In recent years the number of patients treated with ACE inhibitors has increased; however, a relatively small proportion of these patients received adequate therapeutic dosages. Attention to factors that impair proper use of these agents is essential to realize improved outcomes in these patients.
Collapse
Affiliation(s)
- A B Luzier
- School of Pharmacy, University of Buffalo, State University of New York 14260, USA
| | | |
Collapse
|
12
|
Bart BA, Ertl G, Held P, Kuch J, Maggioni AP, McMurray J, Michelson EL, Rouleau JL, Warner Stevenson L, Swedberg K, Young JB, Yusuf S, Sellers MA, Granger CB, Califf RM, Pfeffer MA. Contemporary management of patients with left ventricular systolic dysfunction. Results from the Study of Patients Intolerant of Converting Enzyme Inhibitors (SPICE) Registry. Eur Heart J 1999; 20:1182-90. [PMID: 10448027 DOI: 10.1053/euhj.1998.1481] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
AIMS The reported prevalence of angiotensin-converting enzyme (ACE) inhibitor use in patients with heart failure varies considerably. Recent reports suggest that many patients who could benefit from such therapy are not receiving ACE inhibitors. The Study of Patients Intolerant of Converting Enzyme Inhibitors (SPICE) Registry was established to understand better the demographics, characteristics, and contemporary use of ACE inhibitors in an international registry. METHODS AND RESULTS Between August 1996 and April 1997, each of 105 study centres from eight countries in North America and Europe was invited to review retrospectively the medical records of 100 consecutive patients with left ventricular ejection fractions </=35%. The median age of the 9580 Registry patients was 66 years, 26% were women, the median ejection fraction was 27%, and the primary aetiology of left ventricular dysfunction was ischaemic (63%). Eighty percent of patients were receiving ACE inhibitors. The most common reason for non-use of ACE inhibitors was intolerance (9%). CONCLUSION The SPICE Registry provides a contemporary description of the demographics and management of patients with documented left ventricular systolic dysfunction. The contemporary use of ACE inhibitors (80%) appears to be higher than previously reported and the main reason for non-use is perceived intolerance (9%).
Collapse
|
13
|
McAlister FA, Teo KK, Taher M, Montague TJ, Humen D, Cheung L, Kiaii M, Yim R, Armstrong PW. Insights into the contemporary epidemiology and outpatient management of congestive heart failure. Am Heart J 1999; 138:87-94. [PMID: 10385769 DOI: 10.1016/s0002-8703(99)70251-6] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To evaluate the epidemiology, prognosis, and patterns of practice in patients with chronic congestive heart failure (CHF) treated and followed at a specialized clinic. METHODS Prospective cohort study of consecutive patients referred to and followed up in a specialized heart failure clinic between September 1989 and March 1996. RESULTS Of the 628 patients referred, 566 were confirmed to have CHF. Mean duration of follow-up was 518 +/- 490 days (range 1 to 2192 days). Vital status was available for 99.3% of patients. Mean age at enrollment was 66 years, 68% were men, 67% had an ischemic cause of heart disease, and 78% had systolic dysfunction. Patients with preserved systolic function were older, more often female, had higher mean systolic blood pressures, and a lower prevalence of ischemic heart disease, ventricular arrhythmias, or impaired renal function when compared with those with systolic dysfunction (all P </=.001). Although there was a significant negative trend in survival with decreasing ejection fraction (P =. 03), the survival experience of those with CHF and preserved systolic function did not significantly differ from those with systolic failure (P =.25). Multiple logistic regression analysis showed increased mortality risk was associated with increasing age, New York Heart Association class IV, ischemic cause of disease, elevated serum creatinine level, use of diuretics, and systolic dysfunction, whereas use of beta-blockers was associated with reduced risk. CONCLUSIONS Our data suggest that a specialized outpatient clinic can improve practice patterns in patients with CHF. The high mortality risk in CHF with preserved systolic function suggests the need to find efficacious (and effective) therapies for this condition.
Collapse
Affiliation(s)
- F A McAlister
- Division of General Internal Medicine, University of Alberta, Edmonton, Canada
| | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Abstract
BACKGROUND The purpose of this study was to determine the standard of care provided by academic medical centers for the management of congestive heart failure (CHF). METHODS AND RESULTS The standard of care was estimated by assessing adherence to the treatment guidelines published by the US Agency for Health Care Policy and Research among 522 patients hospitalized at 7 university hospitals with a diagnosis of CHF. Data were abstracted by retrospective chart review. Of the 522 patients analyzed, 435 (83%) had a left ventricular ejection fraction (LVEF) measured or documented. Among these patients, 192 were considered "ideal" candidates for angiotensin-converting enzyme (ACE) inhibitor therapy (ie, with systolic dysfunction [LVEF <40%] and no contraindications to ACE inhibitors). In this cohort of "ideal" candidates, 138 (72%) were receiving ACE inhibitors at hospital discharge, including 60 (44%) who were prescribed doses recommended in large clinical trials. Compliance with patient education guidelines was assessed in all 487 patients who were alive at the time of discharge. Of these patients, 365 (75%) received dietary counseling, 404 (83%) were educated about exercise, 54 (11%) were instructed to follow daily weights, and 468 (96%) were counseled regarding medication compliance. Among the 87 smokers who were alive at time of discharge, 8 (9%) had documented advice to quit smoking. CONCLUSIONS This study indicates that academic medical centers performed fairly well on the assessment of LVEF, the prescription of ACE inhibitors at discharge, and on education regarding diet, exercise, and compliance with medications. However, the results suggest opportunities for improvement in ACE inhibitor dosing and patient education regarding the importance of monitoring daily weights and smoking cessation.
Collapse
Affiliation(s)
- A Nohria
- Section of Cardiovascular Medicine, Department of Medicine, Yale-New Haven Hospital Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT 06520-8025, USA
| | | | | | | | | | | |
Collapse
|
15
|
Abstract
BACKGROUND Over the past 10 years, efforts have been made to control the cost of care for patients with congestive heart failure (CHF) through reducing hospitalizations and shortening lengths of stay. Few data are available regarding the effectiveness of these intervention strategies on a community basis. METHODS AND RESULTS We analyzed the Oregon hospital discharge database. Multivariable methods were used to assess trends while controlling for confounding factors, such as age, sex, and comorbidity. The hospital admission rates for CHF were stable over time in all age groups. The age- and sex-standardized admission rate among people aged 65 years or older decreased slightly from 13.9/1,000 in 1991 to 12.9/1,000 in 1995. The annual hospital readmission rate remained constant over time, with an average rate of 15.3%. The average length of hospital stay decreased from 5.01 days in 1991 to 3.95 days in 1995. The in-hospital mortality rate decreased from 6.9% in 1991 to 4.7% in 1995, independent of length of stay. CONCLUSION We observed stable hospital admission and readmission rates for CHF, accompanied by a decreasing trend in the length of hospital stay and in-hospital mortality. Our findings raise the possibility of improved care management for heart failure over time.
Collapse
Affiliation(s)
- H Ni
- Oregon Heart Failure Project, Oregon Health Sciences University, Portland 97201-3098, USA
| | | | | |
Collapse
|
16
|
Sueta CA, Chowdhury M, Boccuzzi SJ, Smith SC, Alexander CM, Londhe A, Lulla A, Simpson RJ. Analysis of the degree of undertreatment of hyperlipidemia and congestive heart failure secondary to coronary artery disease. Am J Cardiol 1999; 83:1303-7. [PMID: 10235085 DOI: 10.1016/s0002-9149(99)00117-4] [Citation(s) in RCA: 196] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
There is a lack of data evaluating the implementation of guidelines in the management of coronary artery disease (CAD) or congestive heart failure (CHF) in the outpatient setting. We analyzed an administrative data set from the Merck & Co. sponsored national Quality Assurance Program, a retrospective outpatient chart audit of 58,890 adult outpatients from 140 medical practices (80% cardiology only) in the USA with diagnoses of CAD and/or CHF identified from medical claims data. We determined the (1) frequency of lipid documentation and prescription of lipid-lowering agents in patients with CAD, (2) frequency of assessment of left ventricular function and prescription of an angiotensin-converting enzyme inhibitor in patients with CHF, and (3) predictors of medication prescription. Of the 48,586 patients with CAD, 44% had annual diagnostic testing of low-density lipoprotein cholesterol. Only 25% of these patients reached the target low-density lipoprotein cholesterol of < or = 100 mg/dl, and only 39% were taking lipid-lowering therapy, which was less among the elderly than in the younger patients. Of the 16,603 patients with CHF, 64% had diagnostic testing of left ventricular function, and 50% of patients were taking an angiotensin-converting enzyme inhibitor; 67% of patients received medication if they had documented systolic dysfunction. Significant predictors of medication prescription included diagnostic testing, younger age, history of myocardial infarction or coronary artery bypass grafting, hypertension, cardiology specialty, and geographic region. Thus, current practice patterns in the management of CAD and CHF are inadequate. Patient age, diagnostic testing, and practice environment influence medication prescription.
Collapse
Affiliation(s)
- C A Sueta
- Medical Review of North Carolina, Cary, USA
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Abstract
AIMS To describe age- and gender-related prescription patterns of diuretics in community-dwelling elderly, and to compare diuretics to other cardiovascular (CV) medications. METHODS Cross-sectional study of patient-specific prescription data derived from a panel of 10 Dutch community pharmacies. Determination of proportional prescription rates and prescribed daily dose (PDD) of diuretics, cardiac glycosides, nitrates, angiotensin converting enzyme (ACE) inhibitors, beta-adrenoceptor blockers, and calcium channel blockers in all 5326 patients aged 65 years or older dispensed CV medications between August 1st, 1995 and February 1st, 1996. RESULTS Diuretics were prescribed to 2677 of 5326 patients (50.3%), 1325 patients (24.9%) using thiazides and 1198 patients (22.5%) using loop diuretics. Prescription rates of loop diuretics increased from 15.1% in patients aged 65-74 years to 37.2% in patients aged 85 years or older. Rates also increased for digoxin and nitrates. Rates for thiazide diuretics remained unchanged with age; rates for beta-adrenoceptor blockers, ACE inhibitors and calcium channel blockers declined with age. Thiazides were prescribed to 30.1% of women compared with 16% of men (P < 0.001). Average PDD was 135 +/- 117% of defined daily dose (DDD) for loop diuretics, and highest for bumetanide (245 +/- 2.01% of DDD, equivalent to 2.5 +/- 2.0 mg). Average PDD was 74 +/- 40% of DDD for thiazides, and highest for chlorthalidone (100 +/- 49% of DDD, equivalent to 25 +/- 12 mg). CONCLUSIONS Important characteristics of diuretic usage patterns in this elderly population were a steep increase in loop diuretic use in the oldest old, a large gender difference for thiazide use, and high prescribed doses for thiazides.
Collapse
Affiliation(s)
- D J van Kraaij
- Department of Geriatric Medicine, University Hospital Nijmegen, The Netherlands
| | | | | | | | | |
Collapse
|
18
|
Young JB, Gheorghiade M, Uretsky BF, Patterson JH, Adams KF. Superiority of "triple" drug therapy in heart failure: insights from the PROVED and RADIANCE trials. Prospective Randomized Study of Ventricular Function and Efficacy of Digoxin. Randomized Assessment of Digoxin and Inhibitors of Angiotensin-Converting Enzyme. J Am Coll Cardiol 1998; 32:686-92. [PMID: 9741512 DOI: 10.1016/s0735-1097(98)00302-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We sought to study the efficacy of "triple" therapy with digoxin, diuretic and angiotensin-converting enzyme inhibitor (ACEI) compared to other combinations of these drugs in patients with symptomatic left ventricular systolic dysfunction. BACKGROUND Controversy continues concerning the role of combining digoxin with diuretic and ACEI in the initial management of patients with heart failure. METHODS The study utilized data from two studies of digoxin efficacy: Prospective Randomized Study of Ventricular Function and Efficacy of Digoxin (PROVED) and Randomized Assessment of Digoxin and Inhibitors of Angiotensin-Converting Enzyme (RADIANCE). Worsening heart failure defined as augmentation of heart failure therapy or an emergency room visit or hospitalization for increased heart failure was the main outcome measure. RESULTS A total of 266 patients comprising the four treatment groups of the combined PROVED (diuretic alone or digoxin and diuretic) and RADIANCE (ACEI and diuretic, or digoxin, diuretic and ACEI) trials were analyzed. Worsening heart failure occurred in only 4 of the 85 patients who continued digoxin, diuretic and ACEI therapy (4.7%) compared to 18 of the 42 patients (19%) on digoxin and diuretic therapy (p=0.009), to 23 of the 93 patients (25%) on ACEI and diuretic therapy (p=0.001) and to 18 of the 46 patients (39%) on diuretic alone (p < 0.001). Life table and multivariate analysis also demonstrated that worsening heart failure was least likely in patients treated with triple therapy (p < 0.01 vs. all other groups). CONCLUSION Pending definitive, prospective clinical trials, our results argue for triple therapy as the initial management of patients with symptomatic heart failure due to systolic dysfunction.
Collapse
Affiliation(s)
- J B Young
- Department of Cardiology, Cleveland Clinic Foundation, Ohio, USA
| | | | | | | | | |
Collapse
|
19
|
Abstract
The objectives of this study were to assess current practice patterns in pharmacotherapy for congestive heart failure at an academic medical center and to analyze temporal trends in management of congestive heart failure from 1990 to 1995. Records of all patients discharged from the hospital in 1990 or 1995 with a primary diagnosis of congestive heart failure who also underwent echocardiography were found by a search of the hospital's medical records database. All charts were reviewed, and relevant clinical data, including all discharge medications, were recorded. On the basis of echocardiograms, patients were classified as having preserved or impaired left ventricular systolic function (estimated ejection fraction > or =45% versus <45%). The use of digoxin, diuretics, angiotensin-converting enzyme (ACE) inhibitors, calcium and beta-blockers, nitrates, and hydralazine in 1990 and 1995 were compared in subgroups according to left ventricular function. A total of 297 patients were identified who fulfilled study criteria and for whom all pertinent data were available (1990, n = 109; 1995, n = 188). The median age was 74 years; 37.3% of the patients were men, and 45.1% were white. Among patients with impaired systolic function, the proportion receiving either an ACE inhibitor or the combination of nitrates and hydralazine increased from 80.9% in 1990 to 95.4% in 1995 (p = 0.009). In addition, among patients treated with an ACE inhibitor, the proportion receiving an optimal dose increased from 24.3% in 1990 to 61.5% in 1995 (p < 0.001). The use of beta-blockers also increased significantly during this time period (2.1% versus 15.7%; p = 0.031 ). Among patients with preserved ventricular function, the use of ACE inhibitors and beta-blockers increased from 1990 to 1995 (both p < 0.05). The use of other medications did not change for either subgroup. Current use of appropriate vasodilator therapy at an academic medical center is very high and is in accordance with published guidelines for the management of congestive heart failure. The use of vasodilators and beta-blockers has increased significantly since 1990 among patients with congestive heart failure with either impaired or preserved left ventricular contractility.
Collapse
Affiliation(s)
- M W Rich
- Division of Cardiology, Barnes-Jewish Hospital at Washington University, St. Louis, MO 63110, USA
| | | | | |
Collapse
|
20
|
Abstract
Progressive heart disease after the onset of left ventricular dysfunction has typically been attributed to hemodynamic factors. As left ventricular function declines, decreased cardiac output and tissue hypoperfusion lead to compensatory increases in afterload, preload, and heart rate. The purpose of these compensatory responses is to increase cardiac output and maintain tissue perfusion; however, they may also create hemodynamic stress for the failing heart. However, this does not explain the progression of heart failure despite hemodynamic maintenance with pharmacologic therapy. Activation of neurohormonal systems that are essential for homeostasis in the normal heart plays a key role in the progression of heart failure. In acute heart failure, these systems have beneficial effects, but in chronic heart failure their activation produces deleterious effects by increasing the load on the left ventricle and promoting structural remodeling, which may further impair left ventricular function. The issue of neurohormonal activation is an important one in cardiovascular medicine, not only for patients with heart failure but also for patients with hypertension and ischemic heart disease when left ventricular dysfunction is present. As neurohormonal activation may play a pathogenic role in the long-term outcome of patients, interventions that have favorable hemodynamic but unfavorable neurohormonal effects can actually exacerbate cardiac disease and may increase cardiovascular morbidity and mortality. As neurohormonal activation appears to parallel the severity of heart failure, whether assessed according to symptoms or prognosis, an understanding of neurohormonal activation and its interaction with hemodynamic factors is essential for optimizing pharmacologic therapy for cardiovascular disease.
Collapse
Affiliation(s)
- P E Pool
- Reno Cardiology Research Laboratory, Nevada, USA
| |
Collapse
|
21
|
Abstract
Continuing high morbidity and mortality have spurred an ongoing search for new therapeutic agents for patients with congestive heart failure. Calcium antagonists (CAs) have been under active investigation in patients with heart failure since their introduction into clinical medicine, because their anti-ischemic and vasodilator properties were thought to be of potential benefit in this patient population. However, review of published clinical trials of CAs in patients with heart failure reveals that some of these drugs are associated with detrimental effects, including acute hemodynamic deterioration, increased symptoms of heart failure, and increased mortality. The adverse effects of short-acting CAs in patients with heart failure include negative inotropic effects and neurohormonal activation. Long-acting CAs, such as amlodipine and felodipine, had fewer negative inotropic effects, showed less evidence of neurohormonal activation, and were better tolerated in clinical trials. Amlodipine, in combination with an angiotensin-converting enzyme inhibitor, had a neutral effect in patients with ischemic heart failure and an unexplained benefit in a subgroup of patients with non-ischemic cardiomyopathy. Although the preliminary experience with long-acting dihydropyridine CAs in heart failure has been encouraging, safety concerns raised by past trials dictate that no CA can be recommended for the treatment of heart failure at this time.
Collapse
Affiliation(s)
- S Katz
- Heart Failure Center, Columbia-Presbyterian Medical Center, New York, New York, USA
| |
Collapse
|
22
|
|
23
|
Chin MH, Wang JC, Zhang JX, Lang RM. Utilization and dosing of angiotensin-converting enzyme inhibitors for heart failure. Effect of physician specialty and patient characteristics. J Gen Intern Med 1997; 12:563-6. [PMID: 9294790 PMCID: PMC1497161 DOI: 10.1046/j.1525-1497.1997.07110.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
To determine if physician specialty is associated with underutilization and underdosing of angiotensin-converting enzyme inhibitors among patients with heart failure, we reviewed the charts of 214 outpatients with decreased systolic function at an urban academic medical center. Regardless of whether patients were cared for by cardiologists, generalist physicians, or a combination of the two specialities, approximately 75% of the patients were taking an angiotensin-converting enzyme inhibitor. However, only approximately 60% of these patients were taking dosages proved to be efficacious in trials. Emphasis on adequate dosing is needed among all specialty groups.
Collapse
Affiliation(s)
- M H Chin
- Department of Medicine, University of Chicago Medical Center, Ill 60637, USA
| | | | | | | |
Collapse
|
24
|
Chin MH, Friedmann PD, Cassel CK, Lang RM. Differences in generalist and specialist physicians' knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure. J Gen Intern Med 1997; 12:523-30. [PMID: 9294785 PMCID: PMC1497156 DOI: 10.1046/j.1525-1497.1997.07105.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To quantify the extent and determinants of underutilization of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure, especially with respect to physician specialty and clinical indication. DESIGN Survey of a national systematic sample of physicians. PARTICIPANTS Five hundred family practitioners, 500 general internists, and 500 cardiologists. MEASUREMENTS AND MAIN RESULTS Physicians' choice of medications were determined for four hypothetical patients with left ventricular systolic dysfunction: (1) new-onset, symptomatic; (2) asymptomatic; (3) chronic heart failure, on digitalis and diuretic; and (4) asymptomatic, post-myocardial infarction. For each patient, randomized controlled trials have demonstrated that ACE inhibitors decrease mortality or the progression of symptoms. Among the 727 eligible physicians returning surveys (adjusted response rate 58%), approximately 90% used ACE inhibitors for patients with chronic heart failure who were already taking digitalis and a diuretic. However, family practitioners and general internists chose ACE inhibitors less frequently (p < or = .01) than cardiologists for the other indications. Respective rates of ACE inhibitor use for each simulated patient were new-onset, symptomatic (family practitioners 72%, general internists 76%, cardiologists 86%); asymptomatic (family practitioners 68%, general internists 78%, cardiologists 93%): and asymptomatic, postmyocardial infarction (family practitioners 58%, general internists 70%, cardiologists 94%). Compared with generalists, cardiologists were more likely [p < or = .05] to increase ACE inhibitors to a target dosage (45% vs 26%) and to tolerate systolic blood pressures of 90 mm Hg or less [43% vs 15%). CONCLUSIONS Compared with cardiologists, family practitioners and general internists probably underutilize ACE inhibitors, particularly among patients with decreased ejection fraction who are either asymptomatic or post-myocardial infarction. Educational efforts should focus on these indications and emphasise the dosages demonstrated to lower mortality and morbidity in the trials.
Collapse
Affiliation(s)
- M H Chin
- Section of General Internal Medicine, University of Chicago (Ill) Medical Center 60637, USA
| | | | | | | |
Collapse
|
25
|
Edep ME, Shah NB, Tateo IM, Massie BM. Differences between primary care physicians and cardiologists in management of congestive heart failure: relation to practice guidelines. J Am Coll Cardiol 1997; 30:518-26. [PMID: 9247527 DOI: 10.1016/s0735-1097(97)00176-9] [Citation(s) in RCA: 145] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES This study was designed to characterize physician practices in the management of congestive heart failure (CHF) and to determine whether these practices vary by specialty and how they relate to guideline recommendations. BACKGROUND Congestive heart failure is responsible for considerable mortality, morbidity and health care resource utilization. Although there have been important advances in the diagnostic evaluation and treatment of CHF, little information is available on physician practices in this area. METHODS We surveyed physicians concerning their management of patients with CHF. The results were analyzed in multivariate models to determine the relation of diagnostic and treatment approaches to physician specialty, time since training, board certification and volume of patients with CHF. Surveys were sent to a sample of 2,250 family and general practitioners (FP/GPs), internists and cardiologists. Responses were examined in relation to guidelines issued by the Agency for Health Care Policy and Research that had been released 9 months previously. RESULTS Significant differences were found between physician groups with regard to each of the major guideline recommendations. For example, routine evaluation of left ventricular function, a point of emphasis in the guideline, is performed by 87% of cardiologists, but by only 77% of internists and 63% of FP/GPs (p < 0.001 between groups). Angiotensin-converting enzyme inhibitors were used by cardiologists, internists and FP/GPs in 80%, 71% and 60% of patients with mild to moderate CHF, respectively (p < 0.001 between groups). Larger differences were reported in the prescribed dosages of these drugs and their use in patients with renal dysfunction. CONCLUSIONS Cardiologists report practices more in conformity with published guidelines for CHF than do internists and FP/GPs. Because of the large numbers of patients with CHF and their substantial mortality, morbidity and cost of care, these differences may have a major impact on outcomes and health care costs.
Collapse
Affiliation(s)
- M E Edep
- Department of Medicine, University of California, San Francisco, USA
| | | | | | | |
Collapse
|
26
|
Kostis JB, Lacy CR, Cosgrove NM, Wilson AC. Association of calcium channel blocker use with increased rate of acute myocardial infarction in patients with left ventricular dysfunction. Am Heart J 1997; 133:550-7. [PMID: 9141377 DOI: 10.1016/s0002-8703(97)70150-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The Studies of Left Ventricular Dysfunction (SOLVD) assessed the effect of enalapril in patients with systolic left ventricular dysfunction (LVD). We performed retrospective analyses of the association between calcium channel blocker (CCB) use and fatal and nonfatal myocardial infarction (MI) in these patients. MI occurred in 11.5% of 845 patients receiving CCBs versus 7.5% of 2551 patients not receiving CCBs in the enalapril group and in 14.4% of 874 patients receiving CCBs versus 9.3% of 2527 patients not receiving CCBs in the placebo group. By multivariate Cox regression analysis, adjusting for comorbidity, cause and severity of LVD, heart failure, and concomitant drug use, CCB use was an independent predictor of MI (relative risk [RR] 1.37, confidence interval [CI] 1.14 to 1.63). The increase in MI risk was greater among patients with a higher heart rate (RR 1.46, CI 1.14 to 1.86) and lower blood pressure (RR 1.45, CI 1.14 to 1.86). The adjusted risk ratio for all-cause mortality associated with CCB use was 1.14 (CI 1.00 to 1.28; p = 0.0454). In this analysis of patients with LVD, CCB use was associated with significantly increased risk of fatal or nonfatal MI.
Collapse
Affiliation(s)
- J B Kostis
- Department of Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick 08903-0019, USA.
| | | | | | | |
Collapse
|
27
|
Bart BA, Gattis WA, Diem SJ, O'Connor CM. Reasons for underuse of angiotensin-converting enzyme inhibitors in patients with heart failure and left ventricular dysfunction. Am J Cardiol 1997; 79:1118-20. [PMID: 9114778 DOI: 10.1016/s0002-9149(97)00060-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We reviewed the records of 242 patients admitted over 1 year with heart failure and an ejection fraction < or = 45% to assess the use of angiotensin-converting enzyme inhibitors. Most patients were treated with angiotensin-converting enzyme inhibitors. However, an important minority (8%) had no apparent reason for the lack of this treatment, highlighting the need for strategies to increase the use of these beneficial agents.
Collapse
Affiliation(s)
- B A Bart
- Duke University Medical Center, Durham, North Carolina, USA
| | | | | | | |
Collapse
|
28
|
Abstract
OBJECTIVES This study identifies acute precipitants of hospitalization and evaluates utilization of angiotension-converting enzyme inhibitors in patients admitted with congestive heart failure. METHODS Cross-sectional chart-review study was done of 435 patients admitted nonelectively from February 1993 to February 1994 to an urban university hospital with a complaint of shortness of breath or fatigue and evidence of congestive heart failure. RESULTS The most common identifiable abnormalities associated with clinical deterioration prior to admission were acute anginal chest pain (33%), respiratory infection (16%), uncontrolled hypertension with initial systolic blood pressure > or = 180 mm Hg (15%), atrial arrhythmia with heart rate > or = 120 (8%), and noncompliance with medications (15%) or diet (6%); in 34% of patients, no clear cause could be identified. After exclusion of those who were already on a different vasodilator or who had relative contraindications, 18 (32%) of the patients with ejection fractions < or = 0.35 measured prior to admission were not taking an angiotensin-converting enzyme inhibitor on presentation to the hospital. CONCLUSIONS Interventions to improve compliance, the control of hypertension, and the appropriate use of angiotensin-converting enzyme inhibitors may prevent many hospitalizations of heart-failure patients.
Collapse
Affiliation(s)
- M H Chin
- Department of Medicine, Brigham and Women's Hospital, Boston, Mass, USA
| | | |
Collapse
|
29
|
Torre-Amione G, Kapadia S, Short D, Young JB. Evolving concepts regarding selection of patients for cardiac transplantation. Assessing risks and benefits. Chest 1996; 109:223-32. [PMID: 8549188 DOI: 10.1378/chest.109.1.223] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- G Torre-Amione
- Multiorgan Transplant Center, Baylor College of Medicine, Houston, USA
| | | | | | | |
Collapse
|
30
|
Abstract
Treatment of patients with heart failure has become extremely challenging. A complicated interplay of myocardial, hemodynamic, and humoral factors marking this condition requires a delicate balancing of medication use, procedural intervention, and lifestyle changes. Judicious prescription of therapies in stepwise fashion as the syndrome severity worsens (Fig. 2) is critical to success.
Collapse
Affiliation(s)
- J B Young
- Section of Heart Failure and Cardiac Transplantation Medicine, Cleveland Clinic Foundation, Ohio, USA
| |
Collapse
|