Originally published by 2 Minute Medicine® (view original article). Reused on AccessMedicine with permission.

1. Receiving medications from a greater number of drug classes is linked to lower incidence of rehospitalization and death, for patients in heart failure with reduced ejection fraction (HFrEF).

2. Approximately half of HFrEF patients are not receiving medical therapies that follow clinical guidelines established by the American College of Cardiology Foundation/American Heart Association.

Evidence Rating Level: 2 (Good)

Study rundown:

Heart failure (HF) is a debilitating condition most prevalent in elderly populations, characterized by the heart’s weakened abilities to fill the ventricles or eject blood. About 50% of HF patients have a reduced left-ejection fraction of less than 40% (HFrEF). Currently, American guidelines recommend therapy regimens containing at least two of three of: beta-blockers, angiotensin drugs, and mineralocorticoid receptor antagonists, with careful escalation of drug doses to target dosages tailored to the patient’s condition. Despite this however, it is believed that many clinicians do not have their practices aligned with these guidelines, contributing to significant morbidity and mortality associated with the disease, especially in the period following HF hospitalization, with 25% of patients readmitted and 10% of patients dying within 30 days. In this study, researchers attempted to quantify the adherence to clinical guidelines, and to investigate how medical therapy practices for HFrEF patients relate to all-cause mortality and rehospitalization.

The study analyzed outcomes retrospectively, using an existing health records database. The results showed that the greater number of drug classes prescribed, the lower the risk for death and rehospitalization. Despite this however, 45.4% of patients did not receive medical therapies in adherence with the recommended guidelines, receiving either monotherapy or no therapy at all. As well, 46% of patients who received medical therapies did not receive any dose escalation post-discharge. These results show that the clinical guidelines in place appear to be effective at lowering death and rehospitalization rates, but are currently sub-optimally employed with poor adherence rates.

The central strength in this study is the elimination of performance bias, as its retrospective nature allows researchers to accurately quantify adherence without physicians altering their practice due to observation. Further extensions of the study should examine the relationship between the intensity of medical therapies received and a patient’s disease severity however, to better characterize current practices.

In-depth [retrospective cohort study]:

This study’s population and patient data came from the Humana Research Database in Louisville, Kentucky. Patients selected for the study were between 65 and 89 years of age, and were newly diagnosed with HFrEF, with a hospitalization date between 2008 and 2016. There were 17,106 patients in total: The mean age was 77 years, 60% were men, and 83% were white. The primary outcomes analyzed was the time between discharge and first rehospitalization or death, whichever came first, in a 1 year follow-up period. The study found that 23.3% of patients received no therapy, 22.1% received monotherapy, 41.2% of patients received dual therapy, and 13.4% received triple therapy. Altogether, 54.6% of patients received a level of intensity of medical therapy that adhered to clinical guidelines. Compared to patients with no HF medication, those receiving monotherapy had a 32% reduced incidence of death or rehospitalization (n=3777; HR=0.68, 95% CI=0.64-0.71). For dual therapy, it was a 44% reduced incidence (n=7056; HR=0.56, 95% Ci=0.53-0.59), and for triple therapy it was a 55% reduced incidence (n=2286; HR=0.45, 95% CI=0.41-0.50). Finally, 46% of patients who received medication did not receive a dose escalation during follow-up: This was more prevalent in more intense therapies, with 62.6% of monotherapy patients, not receiving dose escalation (41.8% of dual therapy patients, and 29.1% of triple therapy patients).

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