MedicalResearch.com Interview with:
Stephen J. Greene, MD
Fellow, Division of Cardiology
Duke University Medical Center
Durham, NC, USA
Gregg C. Fonarow, MD, FACC, FAHA, FHFSA
Eliot Corday Professor of Cardiovascular Medicine and Science
MedicalResearch.com: What is the background for this study?
Response: Heart failure is a very common medical condition impacting roughly 6 million men and women in the United States, and associated with impaired quality of life, frequent hospitalizations, and high rates of death.
There are over 300,000 deaths each year in the US among patients with heart failure. Half of heart failure patients have heart failure because of a weak heart muscle where the heart cannot eject a normal amount of blood with each heartbeat, a term called “reduced ejection fraction.” Fortunately, there are multiple medications proven in large clinical trials to make people with heart failure with reduced ejection fraction live longer and feel better.
We also have target doses for these medications, which are the doses used in the trials where the medication proved its benefit. These medications and the target doses are strongly recommended in professional guidelines to improve patient outcomes.
To make sure patients have the best outcomes possible, it is important that we work to get patients on these proven medications if at all possible. Unfortunately, prior research has suggested that many patients eligible for these medications in regular outpatient practice do not receive them.
Most of this research is several years old, and there have been a lot of efforts to improve the quality of heart failure care in the meantime. In our study, we wanted to see if there have been improvements in the use and dosing of proven heart failure medications in modern-day practice. We also wanted to determine which patient factors were associated with not receiving a medication, or receiving the medication at a below target dose.
MedicalResearch.com: What are the main findings?
Response: This study involved patients in the CHAMP-HF Registry, which enrolled patients with heart failure with reduced ejection fraction seen in the outpatient clinic. The goal of our study was to assess the types of heart failure medications these patients received and the doses of these medications. We also reviewed patient characteristics to determine the percentage of patients eligible for each medication and the characteristics that were associated with patients not receiving the medication or receiving it at a below target dose.
Overall, our study included 3,518 patients across 150 primary care and cardiology practices across the United States. We saw significant gaps in the utilization and dosing of these important guideline-recommended heart failure medications.
The 3 important categories of heart failure medication we looked at were
1) ACE inhibitors/ARB/ARNI, 2) beta-blocker, and 3) MRA.
Among patients eligible to receive the medication, 27% were not prescribed an ACE inhibitor/ARB/ARNI, 33% were not prescribed a beta-blocker, and 67% were not prescribed an MRA. Even when patients did receive the medication, they generally received it a lower dose below the recommended target. <25% of eligible patients were simultaneously receiving all 3 medication types, and only 1% were simultaneously receiving the target dose of all 3 medications.
Several patient characteristics were associated with lower medication use or dose, including older age, kidney disease, worse heart failure symptoms, and recent hospitalization for heart failure. These associations suggest that sicker patients may be less likely to receive these important medications and less likely to receive them at the recommended dose.
MedicalResearch.com: What should readers take away from your report?
Response: Our new study demonstrates in routine clinical care and outpatient clinical practices across the United States there is dramatic under dosing of guideline-directed medical therapy for heart failure. There is substantial opportunity to improve the care and outcomes for heart failure patients with improved dosing of heart failure medications.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: Our study suggests that much work remains to improve use and dosing of these important guideline-recommended heart failure medications. Unfortunately, when we compare our work to similar work done almost a decade ago, the results suggest that use and dosing of these important medications has not improved over time. As a field, we are fortunate to have medications proven to work, but implementation in general practice is a challenge. Our results suggest that we need to not only redouble our efforts to identify barriers and improve medication use for those that are eligible, but also think creatively to test new strategies and interventions to improve the quality of heart failure care. Given heart failure remains a leading cause of death, hospitalization, and poor quality of life for the general public, we need to do everything possible to utilize all the tools proven beneficial so that patients have the best outcomes possible.
MedicalResearch.com: Is there anything else you would like to add?
Response: Dr. Greene is supported by a U.S. National Institutes of Health (NIH) grant 5T32HL069749-14, a Heart Failure Society of America/Emergency Medicine Foundation Acute Heart Failure Young Investigator Award funded by Novartis, and has received research support from Novartis. Dr. Fonarow has received funding from the National Institutes of Health; and has consulted for Amgen, Bayer, Medtronic, and Novartis.
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