Category: Federal Forum Posters
Purpose: Clinical trials have reported mortality benefits with the use of select beta-blockers, angiotensin converting enzyme inhibitors (ACEi), and angiotensin II receptor blockers (ARB) for patients with heart failure with reduced ejection fraction (HFrEF). However, studies have shown suboptimal use of these agents in a real-world setting, which diminishes the mortality benefit cited by clinical trials. The purpose of this medication use evaluation was to assess adherence to the American College of Cardiology/American Heart Association (ACC/AHA) heart failure guidelines based on initiation and dose titration of medication therapy in patients with HFrEF at a Veterans Affairs Health Care System.
Methods: Eligible patients were identified if they had a diagnosis of HFrEF or “heart failure not otherwise specified” documented in the electronic medical record from January 1, 2015 to January 1, 2018. Patients were included if they had a documented ejection fraction (EF) of 40% or less. Patients were excluded if all EF measurements were greater than 40%, if they had a diagnosis of combined systolic and diastolic or rheumatic heart failure, if beta blocker therapy was first initiated within the past 2 months, or if they were deceased as of July 15, 2018.
The primary outcome measure was percent of patients currently prescribed one of three beta-blockers recommended for heart failure at target dose, defined as metoprolol succinate 200 mg, carvedilol 25 to 50 mg twice daily, or bisoprolol 5 to 10 mg. Secondary endpoints included percent of patients on optimal target doses of evidence-based ACEi and ARB (equivalent to lisinopril 40 mg daily or valsartan 160 mg twice daily) and combination beta-blocker plus ACEi or ARB.
Results: Three hundred eighty-nine unique patients were identified in the initial population sample. Of these, 160 were reviewed for eligibility, and a random sample of 33 patients were included in the analysis.
The percent of patients who had an active prescription for a beta blocker medication was 67% (n=22). Of those who were actively prescribed a beta blocker, 86% (n=19) were using one of three beta blockers recommended for mortality benefit in heart failure. Of all patients, 12.1% (n=4) had an active prescription for an evidence-based beta-blocker and achieved target dose. The percent of patients with an active prescription for either ACEi or ARB was 70% (n=23), while 12.1% (n=4) were on evidence-based ACEi or ARB at optimal target dose.
Ten patients (30.3%) were using combination regimens (beta-blocker plus ACEi or ARB) in which both medications were evidence-based. Only two patients (6.1%) were prescribed an evidence-based combination at target doses. Mean daily doses achieved in the total population sample include 106.25 mg for metoprolol succinate, 21.5 mg carvedilol, and 20 mg lisinopril.
Conclusion: Overall, the rates of initial prescribing of evidence-based beta-blockers and ACEi or ARB for heart failure in a veteran population is on par with respect to real-world evidence, however, few patients achieved optimal target doses. HFrEF patients may achieve greater reduction in mortality risk with further clinical evaluation for titration of evidence-based heart failure medications.
Nicholas Trotta– Pharmacy Resident, New Mexico VA Healthcare System, Utica, NY