Study: Prescription patterns and predictors of aldosterone antagonist use in heart failure

Key Points

Heart failure (HF) guideline-recommended aldosterone antagonist therapy was received by less than one-third of eligible patients participating in a quality improvement registry who had been hospitalized for HF, according to a study published in the Journal of the American Medical Association. The use of the pharmacologic treatment was low among patients with documented contraindications.

The investigators sought to examine prescription patterns and predictors of use of aldosterone antagonist therapy based on the American College of Cardiology/American Heart Association (ACC/AHA) chronic HF management guideline criteria. The ACC/AHA guidelines for prescription of an aldosterone antagonist include 3 components: hospitalization for HF with left ventricular ejection fraction (LVEF) <35%, serum creatinine level <2.5 mg/dL in men and <2.0 mg/dL in women, and serum potassium <5.0 mEq/L. Aldosterone antagonists are recommended for patients with moderate to severe HF and systolic dysfunction, and safety is promoted by adhering to these appropriate levels of serum creatinine and serum potassium prior to use to avoid hyperkalemia.

The researchers undertook an observational analysis of 43,625 patients admitted to the hospital with HF. Patients were discharged home without medical contraindications to aldosterone antagonist therapy from 241 different hospitals participating in the national Get With The Guidelines-HF (GWTG-HF) quality improvement registry between January 2005 and December 2007. GWTG-HF promotes adherence to guideline-based recommendations. Investigator-defined appropriateness criteria and temporal trends were also examined in these hospitalized HF patients.

Prescription of an aldosterone antagonist as based on the 3 component criteria of the ACC/AHA guidelines was as follows: use in patients by LVEF criteria was 29.5%; by serum creatinine criteria use was 32%; and by serum potassium criteria use was 31%. Aldosterone antagonist prescription for each component increased significantly over six 6-month intervals (P<0.002). This was further evaluated in patients with <35% LVEF who received an ACE inhibitor, angiotensin receptor blocker (ARB), or beta blocker; use at discharge was 30.1% and increased significantly over time (P<0.001). Aldosterone antagonist use remained low in patients with HF and preserved systolic function and hypertension. Importantly, it was determined that inappropriate use of aldosterone antagonists was low and this did not alter over the duration of the 3-year study; only 0.5% of patients with a documented contraindication received aldosterone antagonist therapy and only 2.7% received it when they had a higher than recommended creatinine level.

Notably, although the GWTG-HF report indicates that prescription of aldosterone antagonists increased over time, use was lower than expected given clinical trial data indicating substantial reductions in all-cause hospitalization and all-cause mortality. Many factors may have contributed to the slow adoption of the use of these medications.

These data show aldosterone antagonist therapy can be used as specified by guidelines with a minimum of inappropriate use as seen in this hospital-based performance improvement program. Authors comment that greater adoption of the medication may be warranted "given the substantial morbidity and mortality risk faced by patients hospitalized with HF and the established efficacy of aldosterone antagonist prescription in HF."

SOURCE

Albert NM, Yancy CW, Liang L, et al. Use of aldosterone antagonists in heart failure. JAMA. 2009;302:1658-1665.