Category: Cardiology Guidelines

HFrEF Treatment’s Guideline Barrier

Posted on by Jake Fishman

Guideline-directed medical therapies (GDMT) for heart failure have proven to be “profoundly effective at reducing morbidity and mortality,” and yet prescription rates for many HFrEF therapies are far too low and inconsistent.

To unravel this challenge, a UCLA team analyzed VA data from 178k veterans in 306 Hospital Referral Regions (HRRs) across the US.

On a national level, the researchers observed low median nationwide prescription rates for many key HFrEF drug classes, but relatively high rates for others:

  • Beta-blockers – 80%
  • ACEI/ARB/ARNI – 69.3%
  • MRA – 29.2% (some seemed particularly concerned about this)
  • ARNI – 12.2%
  • SGLT2I – 10.3%

A deeper dive into these numbers reveals even greater regional variations, finding:

  • Wide variations across HRRs nationwide and within geographic regions
  • An inverse association between prescription rates and income inequality
  • A strong association between prescription rates and access to cardiology clinics
  • A strong association between prescription rates and VA telehealth use

Noting that drug costs are less of an issue with VA patients, the study and related editorial paid special attention to the role that cardiology clinic and telehealth access played in GDMT compliance. 

  • 60% of HRRs in the top 10% of cardiology clinic visits had above-median GDMT rates
  • 7 of the 10 HRRs with the lowest prescription scores didn’t have a VA cardiology clinic
  • 67% of HRRs in the top 5% of cardiology telehealth visits had above-median GDMT rates
  • 8 of the 10 HRRs with the lowest prescription scores didn’t have any VA cardiology telehealth visits

Given the significant variations within this single health system, and the importance of GDMT adherence, the study and editorial authors proposed a long list of targeted strategies to improve overall heart failure care:

  • Forming multidisciplinary heart failure management team
  • Making guidelines universally available and implementable
  • Seamlessly implementation GDMT into provider workflows, especially the EHR
  • Increased HF medication education, focused on prescription and uptitration 
  • Dedicating more resources to social determinants of HF health 
  • Expanding access to cardiology clinics and telehealth

The Takeaway

Heart failure treatments and diagnostics have come a long way in recent years, but this study illustrates the important role that GDMT compliance will play in order for those major scientific advancements to have a similarly major impact on patient care.

Questioning Antihypertensives for Older Patients

Posted on by Jake Fishman

When clinicians find that an older hospitalized patient has elevated blood pressure, their next step is often to initiate antihypertensive treatment, but a new JAMA Internal Medicine study suggests that many of these patients would be better off having their BPs left unmanaged.

Researchers from Beth Israel, UCSF, and the VA analyzed data from 66k older VA patients hospitalized for non-cardiac conditions who experienced elevated BPs during their first 48 hours of hospitalization.

A sizable 21.3% of the patients (14k) received intensive BP treatments within their first 48 hours. 

  • Those patients were far more likely to experience at least one negative outcome (8.7% vs. 6.9%; weighted odds ratio: 1.28)
  • Their risk of negative outcomes was especially high if they received intravenous antihypertensives (weighted odds ratio: 1.90)
  • And the patients showed no clear benefits from receiving early and intensive BP treatments

Early treatment decisions also appeared to have a major impact on patients’ longer-term BP treatment regimens, as those treated within the first 48 hours ended up receiving far more antihypertensive doses than patients whose treatments started after 48 hours (mean additional doses: 6.1 vs. 1.6).

These results join a growing field of retrospective and observational studies that similarly highlighted the risks of intensive BP therapy, prompting the authors to call for the first RCTs on inpatient BP treatment. 

The authors also advised against initiating intensive BP treatments for non-cardiac patients unless there’s evidence of organ damage, and especially avoiding intravenous antihypertensives, while shifting clinical focus to managing the underlying causes of high BP.

Although many seemed to agree that clinicians should rethink how and when they treat elevated BP in these patients, others cautioned that these results might be biased (e.g. sicker patients are more likely to receive early/intense BP treatment) and aren’t strong enough to justify major changes in BP treatment policies on their own.

The Takeaway
One could make the case that this study is both clinically logical and at risk of statistical bias, and although a RCT would help settle both arguments, a BP RCT doesn’t appear to be coming soon.

With that, clinicians might benefit from acknowledging that early and intensive BP treatment appears to be associated with poor outcomes in non-cardiac patients (retrospectively, anyway), and making sure their BP treatment decisions are only as early and intense as each patient specifically requires.

Algorithm Aversion in HF Care

Posted on by Madeline Kane

Developing risk prediction tools can be resource- and time-intensive. And sometimes, merely developing a working tool isn’t enough to see results. In this randomized clinical trial of heart failure patients, Yale researchers found that providing clinicians with 1-year mortality risk estimates did not improve patient outcomes nor influence decision-making. 

Researchers randomized 3k heart failure patients into “usual-care” and “alert” groups. In the interventional alert group, predicted 1-year mortality rate and other relevant risk information was displayed to clinicians when they opened the order-entry portion of patients’ medical records.

Over a 384-day median follow-up, outcomes between the alert and usual-care groups were nearly identical for: 

  • 1-year mortality (27.1% vs. 26.1%).
  • 30-day hospitalization (19.4% vs. 20.7%).
  • Length of hospital stay (4.4 days vs. 4.3 days).
  • Prescription of heart failure therapies at discharge (48.2% vs. 48.1%).
  • Rates of palliative care referral (10.3% vs. 10.7%).
  • Rates of advanced therapies like cardiac transplants and defibrillator implants.

One explanation for these findings could be that the risk estimates did not add substantially to clinician intuition, thus diminishing their potential benefit. But the authors believe that the null findings are more likely due to “algorithm aversion” – when clinicians favor their intuition over statistical algorithms, even if the algorithms are “objectively superior.” 

The Takeaway

Identifying high-risk patients is critical for managing heart failure. And most of us probably agree that providing risk prediction scores so clinicians can tailor patient interventions is a good thing. But this study shows that these initiatives may not always work as planned, and taking the time to evaluate their efficacy is an essential step toward enacting successful real-world solutions.

Rosuvastatin, Kidney Risks, and a Clinical Takeaway

Posted on by Madeline Kane

New research from Johns Hopkins further confirms that rosuvastatin use may increase the risk of kidney damage, especially at higher doses. 

Researchers gathered data from 152k patients taking rosuvastatin and nearly 800k on atorvastatin over eight years (3.1-year median follow-up) and found that: 

  • Users of rosuvastatin had an 8% higher risk for hematuria (blood in the urine), a 17% higher risk for proteinuria (protein in the urine), and a 15% higher risk for kidney failure requiring replacement therapy.
  • The risk for hematuria and proteinuria in patients with chronic kidney disease (CKD) increased as rosuvastatin dose increased.
  • The two groups avoided myocardial infarction and stroke to similar extents.

Clinical trials and observational studies linked rosuvastatin to signs of kidney damage when the FDA first approved the drug in 2003, which is why the FDA capped the recommended dosage for people with severe CKD at 10mg/day. 

But the Johns Hopkins researchers found that 44% of patients with advanced kidney disease were prescribed a daily dose exceeding the recommended maximum, suggesting that many clinicians are unaware of rosuvastatin’s dosing recommendations. 

The Takeaway

This study reinforces early reports that rosuvastatin may predispose individuals with advanced CKD to kidney toxicity, and reveals that some clinicians prescribe rosuvastatin at excessive doses. As you might expect, the authors suggested it may be wise to reduce the dosage or discontinue rosuvastatin for these patients.  

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