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Improving Survival After Heart Failure

Heart failure (HF) is among the leading causes of hospitalization in the United States, afflicting more than 5.8 million men and women each year. The disease has been associated with substantial morbidity, mortality, and healthcare expenditures. The 5-year mortality rate for HF has been estimated at more than 50%, and roughly $40 billion is spent annually in costs related to HF. Previous studies have shown that there are gaps, variation, and disparities in the use of evidence-based, guideline-recommended therapies for HF. Regardless of the clinical setting, many eligible HF patients do not receive one or more of the therapies that have been proven to be effective in reducing all-cause mortality in clinical trials and analyses. Non-adherence to recommended HF therapies can significantly reduce quality of life and lifespan in sufferers with the disease. Examining Benefits of Proven HF Therapies A study published in the February 21, 2012 Journal of the American Heart Association: Cardiovascular and Cerebrovascular Diseases evaluated the individual and incremental benefits of guideline-recommended therapies. “While certain therapies are recommended for HF patients in national guidelines from the American College of Cardiology and the American Heart Association, our study was the first to examine the specific incremental contribution of each of these therapies in improving survival when combined in a real-world clinical practice,” says Gregg C. Fonarow, MD, who was the lead author on the investigation. The study by Dr. Fonarow and colleagues utilized a nested case-control design that included HF patients who were enrolled in the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) cohort. The analysis involved 1,376...

Battling CKD in Patients with Diabetes

This Physician’s Weekly feature on chronic kidney disease and diabetes was completed in cooperation with the experts at the American Diabetes Association. Each year in the United States, more than 100,000 people are diagnosed with kidney failure, and diabetes is the most common cause of it, accounting for nearly 44% of new cases. Even when diabetes is controlled, it can lead to chronic kidney disease (CKD) and kidney failure. “According to current estimates, about 20% to 30% of people with diabetes have at least some CKD, although not necessarily end-stage renal disease,” explains M. Sue Kirkman, MD. “More patients with diabetes also have very early signs of kidney damage, such as microalbuminuria. Fortunately, we now have interventions to help prevent early CKD from progressing or worsening in people with diabetes.” Diabetic kidney disease takes many years to develop. In some patients, the filtering function of the kidneys is higher than normal in the first few years of the development of diabetes. Over several years, patients may develop low levels of albuminuria—termed microalbuminuria—but the kidneys’ filtration function usually remains normal during this period. Greater amounts of albuminuria (macroalbuminuria) occur in parallel with the kidneys’ filtering function declining, forcing the body to retain various wastes along the way. As kidney disease progresses, physical changes in the kidneys can increase blood pressure. As such, early detection and treatment of even mild hypertension are essential for people with diabetes. Early Screening is Imperative The American Diabetes Association recommends that every patient diagnosed with diabetes be screened for CKD (Table 1). “It’s better to diagnose it early and address problems at that time rather...
Analyzing Poor Medication Adherence After MI

Analyzing Poor Medication Adherence After MI

Approximately, 1.5 million cases of myocardial infarction (MI) occur each year. An estimated 5% to 10% of patients who survive an MI die within the first year after the index event, and half are rehospitalized. Studies have demonstrated that medications such as aspirin, β-blockers, ACE inhibitors, and statins taken after MI are associated with improved short- and long-term outcomes, providing protection against subsequent cardiovascular events. Despite proven benefits, a large proportion of patients who have had an MI appear to discontinue use of their prescribed medications over time. Most medications should be taken indefinitely, but long-term data on factors affecting medication adherence are lacking. New Data on Medication Adherence In a study published in the October 2009 American Journal of Medicine, my colleagues and I published an analysis assessing patients hospitalized with MI from 1997 to 2006 to determine adherence to statins, β-blockers, and ACE inhibitors/angiotensin receptor blockers (ARBs). The study also looked at factors that appeared to be associated with improved adherence. Data demonstrated that adherence to guideline-recommended medications decreased over time, with 3-year medication continuation rates of 44%, 48%, and 43% for statins, β-blockers, and ACE inhibitors/ARBs, respectively. Our findings illustrated that many patients discontinued use of prescribed cardioprotective medications after MI, with less than half continuing medications 3 years after their MI. Results were particularly striking because the study included patients who were well-insured with relatively low out-of-pocket expenses for prescription drugs. Considering the insurance status of the patients assessed, adherence is presumably even worse among the general population. Assessing Adherence Factors A potential cause of poor medication adherence after MI may be a “knowledge translation...
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