Persistent Use of Evidence-Based Pharmacotherapy in Heart Failure Is Associated With Improved Outcomes

Abstract

Background-Undertreatment with recommended pharmacotherapy is a common problem in heart failure and may influence prognosis. We studied initiation and persistence of evidence-based pharmacotherapy in 107 092 patients discharged after first hospitalization for heart failure in Denmark from 1995 to 2004. Methods and Results-Prescriptions of dispensed medication and mortality were identified by an individual-level linkage of nationwide registers. Inclusion was irrespective of left ventricular function. Treatment with renin-angiotensin inhibitors (eg, angiotensin-converting enzyme inhibitors and angiotensin-2 receptor blockers), ␤-blockers, spironolactone, and statins was initiated in 43%, 27%, 19%, and 19% of patients, respectively. Patients who did not initiate treatment within 90 days of discharge had a low probability of later treatment initiation. Treatment dosages were in general only 50% of target dosages and were not increased during long-term treatment. Short breaks in therapy were common, but most patients reinitiated treatment. Five years after initiation of treatment, 79% patients were still on renin-angiotensin inhibitors, 65% on ␤-blockers, 56% on spironolactone, and 83% on statins. Notably, multiple drug treatment and increased severity of heart failure was associated with persistence of treatment. Nonpersistence with renin-angiotensin inhibitors, ␤-blockers, and statins was associated with increased mortality with hazard ratios for death of 1.37 (95% CI, 1.31 to 1.42), 1.25 (95% CI, 1.19 to 1.32), 1.88 (95% CI, 1.67 to 2.12), respectively. Conclusions-Persistence of treatment was high once medication was started, but treatment dosages were below recommended dosages. Increased severity of heart failure or increased number of concomitant medications did not worsen persistence, but nonpersistence identified a high-risk population of patients who required special attention. A focused effort on early treatment initiation, appropriate dosages, and persistence with the regimen is likely to provide long-term benefit. (Circulation. 2007;116:737-744.)

The Pharmacist Role in Predicting and Improving Medication Adherence in Heart Failure Patients

“…6,23 Smaller cohort studies in U.S. patients had similar findings regarding race, where minority or nonwhite race were significant predictors for nonadherence. 8,21 Other interesting findings from large cohort studies with follow-up ranging from 1 to 5 years in the United States, 6,23,32 Canada, 29 and European countries 22,27 identified those with more severe HF, 27 a greater a reduction in quality of life. [8][9][10][11][12][13][14] Furthermore, the Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity (CHARM) study demonstrated that increased adherence to HF medications was associated with a 35% reduction in mortality (hazard ratio [HR] = 0.65, 95% confidence interval [CI] = 0.57-0.75, P < 0.0001).…”

“…6,8,10,12,[21][22][23][24][25][26][27][28][29][30][31][32] Table 1 may assist the health care provider in recognizing predictors that may impact adherence to HF medications. Table 2 depicts a summary of the studies identifying predictors of decreased 6,8,10,[21][22][23][24][25][26]28,29,32 and increased 8,12,22,[26][27][28]30,31 HF medication adherence. Large, observational cohort studies extracting adherence and demographic data from health insurance claims databases or HF registries with 2 to 4 years of follow-up data from the United States found some similar significant predictors for nonadherence, including male gender or nonwhite race.…”

Effect of antihypertensive therapy on hospitalization and mortality among uncomplicated and high risk hypertensive patients

“…Existing publication focus generally on single cohort of patients [8,16,[18][19][20][21]. We have chosen to compare different cohorts of hypertensive patients managed in the same geographical, clinical and organizational setting in order to have a comprehensive evaluation of the real world.…”

Metformin is associated with improved left ventricular diastolic function measured by tissue Doppler imaging in patients with diabetes

“…For other medications, patients were considered to be in treatment with a specific agent if they had claimed at least one prescription in the 6 months preceding echocardiography. To determine concomitant pharmacotherapy, the following agents (ATC codes) were identified: b-blockers (C07), statins (C10A), angiotensin-converting enzyme inhibitors and angiotensin-2 antagonists (C09), loop diuretics (C03C), thiazides (C03A), spironolactone (C03D), and calcium channel blockers (C08), as done previously (18).…”