Evolving Patterns of Use and Appropriateness of Aldosterone Antagonists in Heart Failure

1. Evolving Patterns of Use and Appropriateness of Aldosterone Antagonists in Heart Failure Nancy M. Albert, PhD, RN; Clyde W. Yancy, MD; Li Liang, PhD; Adrian F. Hernandez, MD; Eric D. Peterson, MD, MPH, Xin Zhao, MS, Christopher P. Cannon, MD; Gregg C. Fonarow, MD Albert et al. JAMA. 2009;302(15):1658-1665.

2. Background Aldosterone antagonists are recommended in patients with moderate-to-severe heart failure (HF) and systolic dysfunction. Prior studies suggest underutilization of aldosterone antagonists in eligible patients as well as overuse in settings where therapy may be harmful. Albert et al. JAMA. 2009;302(15):1658-1665.

3. Introduction Data support the use of aldosterone antagonists in heart failure patients. Aldosterone antagonists are underutilized in eligible patients. The GWTG Program has been shown to improve the appropriate use of aldosterone antagonist therapy in heart failure patients. Albert et al. JAMA. 2009;302(15):1658-1665.

4. Objective The purpose of the paper was to evaluate whether a hospital-based quality program such as GWTG improves the use of aldosterone antagonist therapy in the appropriate patient population. Albert et al. JAMA. 2009;302(15):1658-1665.

5. Methods • Observational analysis • Outcome measures were prescription and predictors of use of aldosterone antagonists, based on guideline criteria. • 43,625 patients admitted with HF and discharged home from 241 hospitals participating in the Get With The Guidelines--HF quality improvement registry between 2005-2007. Albert et al. JAMA. 2009;302(15):1658-1665.

6. Results • Rates of inappropriate use of aldosterone antagonists are low: 0.5% use in patients with documented contraindications and 2.7% use in patients with higher than recommended creatine levels. • The data suggest that less than one third of eligible HF patients were prescribed an aldosterone antagonist. • Only 32.5% (4,087 out of 12,565) of eligible HF patients were prescribed aldosterone antagonist therapy at discharge. Over the study period, the number of eligible HF patients receiving an aldosterone antagonist increased from 28% to 34%. • The data showed that the following patient populations received aldosterone antagonist at a higher rate: young patients, African Americans, those with lower systolic blood pressures, a history of implantable cardioverter-defibrillator use, depression, alcohol use, and pacemaker implantation, and those with no history of renal insufficiency. • Increases in aldosterone antagonist usage in eligible patients were small from 2005-2007 and stayed below 35% while inappropriate aldosterone antagonist use remained low. Albert et al. JAMA. 2009;302(15):1658-1665. Albert JAMA 2009

7. Conclusions • These data suggest that in the context of a hospital-based performance improvement program, aldosterone antagonist therapy can be used according to guidelines with little inappropriate use. • Given the substantial morbidity and mortality risk faced by patients hospitalized with HF and the established efficacy of aldosterone antagonist use in HF, a stronger uptake of aldosterone antagonist therapy indicated by evidence-based guidelines may be warranted. Albert et al. JAMA. 2009;302(15):1658-1665.