Lack of evidence of lower 30-day all-cause readmission in Medicare beneficiaries with heart failure and reduced ejection fraction discharged on spironolactone

Abstract

Background Therapy with evidence-based heart failure (HF) medications has been shown to be associated with lower risk of 30-day all-cause readmission in patients with HF and reduced ejection fraction (HFrEF). Methods We examined the association of aldosterone antagonist use with 30-day all-cause readmission in this population. Of the 2443 Medicare beneficiaries with HF and left ventricular EF ≤35% discharged home from 106 Alabama hospitals during 1998–2001, 2060 were eligible for spironolactone therapy (serum creatinine ≤2.5 for men and ≤2 mg/dl for women, and serum potassium <5 mEq/L). After excluding 186 patients already receiving spironolactone on admission, the inception cohort consisted of 1874 patients eligible for a new discharge prescription for spironolactone, of which 329 received one. Using propensity scores for initiation of spironolactone therapy, we assembled a matched cohort of 324 pairs of patients receiving and not receiving spironolactone balanced on 34 baseline characteristics (mean age 72 years, 42% women, 33% African American). Results 30-day all-cause readmission occurred in 17% and 19% of matched patients receiving and not receiving spironolactone, respectively (hazard ratio {HR}, 0.92; 95% confidence interval {CI}, 0 64 1.32; p=0.650). Spironolactone had no association with 30-day all-cause mortality (HR, 0.84; 95% CI, 0.38–1.88; p=0.678) or HF readmission (HR, 0.74; 95% CI, 0.41 1.31; p=0.301). These associations remained unchanged during 12 months of post-discharge follow-up. Conclusion A discharge prescription for spironolactone had no association with 30-day all-cause readmission among older, hospitalized Medicare beneficiaries with HFrEF eligible for spironolactone therapy.

Mineralocorticoid receptor antagonist use following heart failure hospitalization

“…Reasons for not prescribing MRAs were not documented in the vast majority of cases. These results are consistent with several previously published retrospective studies examining utilizing of MRAs in patients with systolic heart failure . In a large cohort of patients followed in the Swedish HF Registry, only 40% of eligible patients were receiving an MRA.…”

“…Based on compelling evidence from these trials, MRAs received Class I recommendations in both American and European guidelines in patients with HF with reduced ejection fraction (HFrEF) . Although considerable variability in MRA use has been reported, most studies indicate that a substantial proportion of eligible HF patients are not taking these drugs . Hospitalization because of exacerbation of HF is common in HFrEF patients and has been identified as a potent risk factor for subsequent morbidity and mortality.…”

Mineralocorticoid receptor antagonist pattern of use in heart failure with reduced ejection fraction: findings from BIOSTAT‐CHF

“…Many reports of ‘real‐life’ observational data pointed to a lack of association of MRA therapy with clinical benefit, in contrast with the findings of multiple randomized clinical trials. No matter how extensive are adjustments in statistical analyses, such observation data are usually fraught with residual bias . We hypothesize that one of the major and often overlooked biases is the wrong assumption that patients prescribed MRA therapy at baseline keep their medications unchanged throughout the course of the observation period.…”

Digoxin use and lower risk of 30‐day all‐cause readmission in older patients with heart failure and reduced ejection fraction receiving β‐blockers

“…The role of aldosterone antagonists in real-world older patients with HFrEF remains unclear. 36,37 HF remains a leading cause for hospital readmission. Few interventions appear to be effective in lowering the risk of 30-day allcause readmission in HF.…”

“…39 However, β-blockers and spironolactone have not been shown to be associated with 30-day allcause readmission. 37,40 Digoxin is a relatively inexpensive and generally safe drug that is approved by the US Food and Drug Administration for use in patients with chronic HF. 41 Findings from the current study suggest that digoxin may be useful in lowering the risk of readmission in contemporary patients with HFrEF receiving β-blockers.…”