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...