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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...

Adopting Aldosterone Antagonist Therapy

Randomized clinical trials on the use of aldosterone antagonists in eligible patients with heart failure have shown an incremental 15% to 30% reduction in all-cause mortality. They also have been associated with a substantial risk reduction in the likelihood of rehospitalization or first-time hospitalizations for heart failure. Due to robust supporting data, aldosterone antagonists have been advised as Class I recommendations in the American College of Cardiology/American Heart Association (AHA) guidelines since 2005 for individuals with moderate-to-severe heart failure and for those with post-myocardial infarction left ventricular dysfunction. Slow Adoption of Evidence-Based Therapy Despite data supporting its efficacy, adoption of aldosterone antagonist therapy for the treatment of heart failure in eligible patients has been slow. In the October 21, 2009 JAMA, my colleagues and I published an observational analysis among patients who were admitted with heart failure in 241 participating hospitals in the AHA’s Get With the Guidelines—Heart Failure (GWTG-HF) quality improvement program. This national quality improvement program was designed to promote adherence to guideline-based recommendations. The GWTG-HF program tracked aldosterone antagonist therapy use, indications, contraindications, and laboratories of 43,000 patients hospitalized with heart failure during the study timeframe. Results demonstrated that: Less than one-third of heart failure patients eligible for aldosterone antagonist therapy (and without documented contraindications) were treated. Prescription of aldosterone antagonists at discharge varied widely among hospitals. Appropriate use of aldosterone antagonist therapy was less common among the elderly; Caucasians; those with lower systolic blood pressure; those without implantable cardioverter-defibrillators or pacemakers; those without a history of alcohol use or depression; and those with a history of renal insufficiency. Rates of inappropriate use were infrequent. Concerns...
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