ACE inhibitors, ARBs control CHF

CHF is a common condition. About 5 million people in the United States have heart failure, resulting in about 300,000 deaths each year. Many patients experience acute episodes involving trips to the emergency room. Heart failure is one of the most common reasons people are admitted to the hospital, and the most common reason for readmission. Between 29% to 47% of elderly heart failure patients are readmitted for that condition within three to six months after an initial hospitalization.

Various medications are used to control CHF: ACE (angiotensin-converting enzyme) inhibitors; ARBs (angiotensin receptor blockers); beta-adrenergic blockers; aldosterone antagonists; vasodilators; diuretics; and digitalis.

In general, patients with heart failure with left ventricular problems should take both an ACE inhibitor and a beta-blocker, and usually a diuretic as well. ARBs are recommended for patients who cannot tolerate ACE inhibitors.

"No data are available showing that any ACE inhibitor is more effective than any other for treatment of heart failure or in its effects on symptoms or survival," says Mark Abramowicz, MD, editor of The Medical Letter on Drugs and Therapeutics, a non-profit newsletter that critically appraises drugs. "The ACE inhibitors shown in the chart have been shown in clinical trials to be effective in recommended doses in improving outcomes."

Candesartan and valsartan are the only ARBs approved by the FDA for treatment of heart failure. "Many Medical Letter consultants believe that all ARBs could be effective for this indication, but effective doses are best established for candesartan and valsartan," says Dr. Abramowicz.

RETAINING FLUIDS

Most patients with CHF experience fluid retention. Diuretics relieve these symptoms, although their effect on survival is unknown. However, patients who consume large amounts of sodium or who take nonsteroidal anti-inflammatories (which block diuretics) may continue to retain fluids.

Group Health, with about 600,000 members in Washington state and northern Idaho, has developed a sophisticated transition program to aid members who have been treated in the hospital for CHF.

"This goes far beyond discharge planning," says Barbara Wood, director of complex care management, who is responsible for both hospital-based care management and clinic-based case management. "We coach them based on the four pillars of transition."

The pillars were developed by Eric Coleman, MD, at the University of Colorado Health Sciences Center.

Dr. Coleman's work emphasizes four specific areas of patient self-management: medications; use of a dynamic patient-centered health record; timely primary care/specialty care follow up; knowledge of red flags that indicate a worsening in their condition and ways to respond.

Group Health patients have at least one meeting with a nurse while they're still in the hospital to discuss their medications and appointments needed for continuing care. They talk about warning signs to watch out for once they're back home and receive a discharge packet with detailed information related to their condition.

"We talk with them about their new medications, and the fact that they may need to throw out some older medications," says Wood. "It's not uncommon for us to help them call and schedule follow-up appointments right there from the hospital room."

Within 24 to 48 hours after discharge, a case manager specializing in heart failure calls the patient for follow up. The nurse completes an over-the-phone assessment, and if the patient needs medication adjustments and continued monitoring, he or she is admitted to Group Health's chronic heart failure case management program. Nurses with advanced training in care management call the patient as often as needed, perhaps once a week, perhaps once a day.

"With a patient who is quite unstable, the nurse may call in the morning and then talk to them again in the afternoon," Wood says.

Nurse case managers in the program offer the patient education about diet and exercise. They work within the cardiologist's office, which facilitates needed medication changes.

"We try to set it up so when the patient comes in to see the doctor, they also meet the nurse case manager," Wood says. "We find, especially with our senior citizens, that if they meet the nurse and have at least one face-to-face conversation, the telephonic work goes much more smoothly."

Group Health data for those in case management for CHF shows there has been a substantial decrease in readmission rate during the 12-month period after hospitalization for this condition.

"We believe our hospital transition management program has been very effective in contacting patients and getting them involved in case management," Wood says. "We expect the transition program will show significant results in reducing the number of readmissions within 30 days of discharge."

This article is based on information supplied by The Medical Letter ( http://www.medicalletter.org/), a non-profit organization that publishes newsletters offering critical appraisals of new drugs and comparative reviews of older drugs. The Medical Letter is completely independent of the pharmaceutical industry. It is supported entirely by subscription sales and accepts no advertising, grants or donations. Institutional site license inquiries can be sent to info@medicalletter.org
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Elaine Zablocki has been reporting on healthcare for more than a dozen years.