Importance of In‐Hospital Initiation of Evidence‐Based Medical Therapies for Heart Failure: Taking Advantage of the Teachable Moment

Abstract

Patients with heart failure (HF) face a very high risk of hospitalizations and mortality. Angiotensin-converting enzyme (ACE) inhibitors, β blockers, and aldosterone antagonists have been demonstrated to be life-prolonging treatments for HF in a spectrum of patients, including those at high risk for developing left ventricular (LV) systolic dysfunction and those with asymptomatic and symptomatic LV systolic dysfunction.1 In more than 50 placebo-controlled trials involving over 17,000 patients with LV systolic dysfunction, ACE inhibitors and β blockers have been shown to alleviate symptoms, improve clinical status, and reduce the risk of death or the combined risk of death and rehospitalization. The benefits of β blockade are additive in patients already on ACE inhibitors.1 Aldosterone receptor antagonists have also been demonstrated to reduce the risk of mortality in patients with severe HF and more mild HF symptoms after myocardial infarction.1,2 Despite the compelling scientific evidence that ACE inhibitors, aldosterone antagonists, and β blockers reduce hospitalizations and mortality in patients with HF, these life-prolonging therapies continue to be underutilized. A number of studies in a variety of clinical settings have documented that a significant proportion of patients with HF are not receiving treatment with these national guideline-recommended, evidence-based therapies when guided by conventional care.3–5 Despite the favorable effect on morbidity and mortality that has been demonstrated by the use of ACE inhibitors, studies indicate that only 48% of patients with prior HF were receiving these agents at the time of hospitalization, and that only 60%–70% of eligible HF patients received ACE inhibitors at discharge.4 This underutilization has been emphasized by a major review of longitudinal national data on outpatient use of ACE inhibitors for HF.5 In one dataset, ACE inhibitor use increased from 18% in 1990 to 41% in 1999, but its use dropped to 28% in 2000.5β blockers, both at hospital discharge and in the outpatient setting, are similarly underused in HF patients, despite the fact that the mandate for their use is at least as strong as that for ACE inhibition. The Acute Decompensated Heart Failure National Registry (ADHERE)4 reported a similar statistic, with only 47% of chronic HF patients with previously diagnosed systolic dysfunction receiving a β blocker on an outpatient basis before admission to the hospital. A recent randomized trial demonstrated that under conventional physician-directed care, only 27% of eligible chronic HF patients were initiated on β-blocker therapy on an outpatient basis.6 In this issue of Congestive Heart Failure, Howard and Shireman7 add to the literature reporting treatment gaps in the use of evidence-based therapies for HF (p. 124). The investigators examined HF drug utilization patterns in Medicaid patients before and after a HF-related hospitalization, using retrospective claims analyses from the time period of 2000–2001. Before hospitalization, less than one third of patients were receiving an ACE inhibitor, angiotensin receptor blocker (ARB), or a β blocker. Following hospitalization, ACE inhibitor, ARB, and β-blocker therapy usage remained low, with only 36.5% of eligible patients treated with ACE inhibitors and 40% with β blockers. In this Medicaid cohort, HF-related hospitalizations failed to result in improved HF therapy. This HF treatment gap results from a variety of complex issues, including lack of systems and disease management programs.3 This gap in β-blocker therapy may be due in part to persisting perceptions, despite recent evidence to the contrary, that it should be delayed until HF patients have been stable for 2 to 4 weeks after hospital discharge, and that its initiation results in a substantial risk of worsening HF. Conversely, recent clinical trial evidence substantiates that β blockers can be safely initiated in-hospital for HF and that there are early benefits including reduced risk of mortality and hospitalization for worsening HF.8 The Initiation Management Predischarge: Process for Assessment of Carvedilol Therapy for Heart Failure (IMPACTHF),8 a multicenter, open-label trial, involved 363 HF patients with an LV ejection fraction ≤0.40, who were admitted for an episode of HF decompensation. Patients were randomized to receive initiation of carvedilol therapy before hospital discharge (once the HF decompensation was successfully treated), or to usual care (initiation of any β blocker 2–4 weeks after hospitalization and when the patient is stable). At the end of 60 days, 91% of the predischarge initiation patients were on carvedilol vs. 73% of patients in the post-discharge, physician-discretion initiation group (pl0.0001) receiving any β blocker.8 It has become evident that in-hospital initiation of evidence-based cardiovascular therapies and patient education have a positive impact on long-term patient compliance and clinical outcomes.3 There is an important opportunity to improve the process of care and enhance the quality of care in the hospital by taking advantage of this teachable moment.3 The Organized Program to Initiate Life-Saving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF)9 project is an example of one initiative that is designed to improve the medical care and education of hospitalized HF patients and to accelerate the initiation of evidence-based, guidelinerecommended HF therapies by starting these lifesaving therapies before hospital discharge. OPTIMIZE-HF integrates both a hospital-based process of care improvement program and a web-based registry that allows physicians the opportunity to benchmark their use of treatment against regional or national use. The program uses established treatment algorithms, care maps, standing orders, and educational initiatives to encourage its adoption by providers. The registry tracks data on HF conditions, medications at admission and discharge, rehospitalizations and deaths, and discharge status and instructions, and stresses compliance with instructions to advance the understanding of the best approaches in initiating optimal HF management. Preliminary data from OPTIMIZE-HF10 suggest dramatic improvements in the use of evidence-based therapy at the time of hospital discharge and during 60–90 days' follow-up. The American Heart Association's (AHA's) Get With the Guidelines (GWTG) program is an acute-care, hospital-based, quality improvement program designed to help close the treatment gap in cardiovascular disease, significantly improve patient outcomes, and move the AHA closer to its 2010 goal of reducing death, disability, and risk by 25%. The AHA has recently launched a GWTG program module focused on HF. Ensuring in-hospital initiation of evidence-based, guideline-recommended therapies in HF patients with stabilized systolic dysfunction, in the absence of contraindications or intolerance, could substantially improve treatment rates, reduce the risk of future hospitalizations, and prolong life. Further efforts are clearly needed to implement systems and disease management programs to increase the use of evidence-based therapies in the hospital and in outpatient settings to reduce the substantial HF morbidity and mortality risk.