Evaluation of the prescribing practice of guideline-directed medical therapy among ambulatory chronic heart failure patients

Abstract

Background Studies have demonstrated that heart failure (HF) patients who receive direct pharmacist input as part of multidisciplinary care have better clinical outcomes. This study evaluated/compared the difference in prescribing practices of guideline-directed medical therapy (GDMT) for chronic HF patients between two multidisciplinary clinics—with and without the direct involvement of a pharmacist. Methods A retrospective audit of chronic HF patients, presenting to two multidisciplinary outpatient clinics between March 2005 and January 2017, was performed; a Multidisciplinary Ambulatory Consulting Service (MACS) with an integrated pharmacist model of care and a General Cardiology Heart Failure Service (GCHFS) clinic, without the active involvement of a pharmacist. Results MACS clinic patients were significantly older (80 vs. 73 years, p < .001), more likely to be female (p < .001), and had significantly higher systolic (123 vs. 112 mmHg, p < .001) and diastolic (67 vs. 60 mmHg, p < .05) blood pressures compared to the GCHF clinic patients. Moreover, the MACS clinic patients showed more polypharmacy and higher prevalence of multiple comorbidities. Both clinics had similar prescribing rates of GDMT and achieved maximal tolerated doses of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in HFrEF. However, HFpEF patients in the MACS clinic were significantly more likely to be prescribed ACEIs/ARBs (70.5% vs. 56.2%, p = 0.0314) than the GCHFS patients. Patients with both HFrEF and HFpEF (MACS clinic) were significantly less likely to be prescribed β-blockers and mineralocorticoid receptor antagonists. Use of digoxin in chronic atrial fibrillation (AF) in MACS clinic was significantly higher in HFrEF patients (82.5% vs. 58.5%, p = 0.004), but the number of people anticoagulated in presence of AF (27.1% vs. 48.0%, p = 0.002) and prescribed diuretics (84.0% vs. 94.5%, p = 0.022) were significantly lower in HFpEF patients attending the MACS clinic. Age, heart rate, systolic blood pressure (SBP), anemia, chronic renal failure, and other comorbidities were the main significant predictors of utilization of GDMT in a multivariate binary logistic regression. Conclusions Lower prescription rates of some medications in the pharmacist-involved multidisciplinary team were found. Careful consideration of demographic and clinical characteristics, contraindications for use of medications, polypharmacy, and underlying comorbidities is necessary to achieve best practice.

The Prescription Pattern of Heart Failure Medications in Reduced, Mildly Reduced, and Preserved Ejection Fractions

“…In the present study, IHD was consistently associated with a higher prescription score irrespective of HF phenotype. These findings are consistent with a previous study in which IHD was found to be a positive predictor of β-blocker prescription in patients with HFrEF and HFpEF [5].…”

“…The baseline characteristics of patients with HF were similar to previously published studies [4,5]. Patients with HFrEF were more likely to be younger and have ischaemic cardiovascular diseases, and less likely to have hypertension compared to patients with HFpEF [4,5]. However, diabetes was observed more frequently in patients with HFpEF compared to HFrEF and HFmrEF (p = 0.037) in the present study, whereas in the CHARM and ESC-HF long-term registry cohorts, the proportion of patients with diabetes was similar across all three phenotypes (p = 0.14 and p = 0.71, respectively) [14,15].…”

“…The baseline characteristics of patients with HF were similar to previously published studies [4,5]. Patients with HFrEF were more likely to be younger and have ischaemic cardiovascular diseases, and less likely to have hypertension compared to patients with HFpEF [4,5].…”

“…A total score of four points or above (any two drugs prescribed at a higher dose or all three drugs prescribed with at least one at a higher dose) was observed in approximately 40.0%, 30.6%, and 25.3% of patients with HFrEF, HFmrEF, and HFpEF, respectively (Table 1 and Figure 1B). The median [IQR] H2FPEF score was five [4][5][6][7] in patients for whom all variables were available (Table 3).…”

“…Guidelines have recommended the highest tolerated dose of drug treatment for HFrEF for years and have recently extended this approach to HFmrEF for ACEi/ARBs, β-blockers, and MRAs [1,2]. Although recent studies show that the majority of patients with HFrEF are prescribed ACEi/ARBs (ranging from 60% to 89%) and β-blockers (ranging from 67% to 88%), only a small proportion are prescribed the target dose in community settings (17% to 54%) [3][4][5][6] with lower doses possibly partially related to therapeutic inertia [7]. A number of factors impact drug prescription, including age, comorbidities, and particularly renal function.…”