Congestive Heart Failure Medications Research Articles

Systolic Heart Failure and Optimization of Medical Therapy: A Quality Improvement Study

Introduction: Congestive heart failure (CHF) accounts for significant medical costs and patient mortality. There are ways to mitigate these parameters by providing patient and provider education, optimizing medications, and applying life-saving devices with a referral for a left ventricular assist device (LVAD) when appropriate. We retrospectively observed the charts of 40 patients at our Dayton Veterans Affairs Medical Center (VAMC) for areas of improvement. Methods: Charts were manually reviewed over 2019 for ejection fraction (EF) at the time of diagnosis and ischemic cardiomyopathy (ICM) vs. nonischemic cardiomyopathy (NICM) etiology of heart failure. Information on the titration of beta-blockers (BB), angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARBs), and advanced heart failure medications was collected. Readmission rates and heart failure follow-up appointment rates were gathered, and further details were investigated regarding the application of a life vest and automatic implantable cardioverter-defibrillator (AICD) when clinically appropriate. Results: Median EF for patients was 34%, consistent with systolic heart failure. 65% of patients had ICM. For medications, BB was maximally titrated for 85% of patients within a wide data range. ACE-I/ARBs titration was appropriate in 75% of patients. An average of 4.7 dose adjustments for BB and 3.6 dose adjustments for ACE-I/ARBs occurred. Advanced CHF medications were rarely prescribed. Exacerbation rates were 60%, from 1–5 readmissions and an average of 1.07 readmissions. 98% of patients received CHF-specific follow-up after each CHF admission. 60% were eligible for advanced life support devices, 25% were offered life vests, and 62% were offered AICD. No patient was referred to a tertiary center for LVAD. Conclusion: We should work towards 100% medication titration to improve outcomes, especially BB which is known to have morbidity value. We can continue to reduce heart failure readmission rates by providing patient and provider education and continuing to do well at heart failure follow-up appointments. Life vest and AICD should be offered more consistently, and tertiary referral to receive LVAD should remain offered per standard of care.

Impact of lockdown in patients with congestive heart failure during the Covid-19 pandemic

BackgroundCongestive heart failure (CHF) alters the course of COVID-19 (C19); pandemic and lockdown can destabilize CHF.PurposeTo evaluate impact of lockdown in CHF patients.Methods150 out patients from the HF Clinic of our hospital were invited to answer t o a phone-call interview during the 7th week of first C19 lockdown.Results124 questionnaires were fit for analysis. Almost all patients declared to respect the nationwide lockdown policies. More than one fifth felt worse than before the lockdown and almost one fourth declared a significant psychologic distress (Kessler-6 score≥ 5). Approximately 10% declared modifications of their CHF medications, always on medical prescription. No patients declared a medication supply failure. Decrease in physical activity was common, almost twice as much in urban than in rural population (50.0 vs 26.2%, P = 0.009). Almost half declared increased screen time and 4 of the 9 smokers increased tobacco consumption. Adherence to dietary counselling was reduced by 17.7% of patients. Increase in weight and HF symptoms were commonly reported. During lockdown time frame, 23 patients who benefitted from a teleconsultation, of whom 16 switched from a planned physical examination they cancelled (Fig. 1).ConclusionsOur patients with CHF exhibited weel-being impairment and unhealthy behaviours, thus suggesting increased risk of future events. Medication adherence was not diminished and the reduction in care access was counterbalanced by a switch toward telehealth. This work was supported by a grant from Dijon Football Côte d’Or and CHU Dijon Bourgogne.

Metronomic Chemotherapy with Toceranib Phosphate for Treatment of a Chemodectoma in a Dog

A 10-year-old, spayed, female Cocker Spaniel was referred to our hospital with a history of a cough and dyspnea. The patient was tentatively diagnosed with a chemodectoma based on clinical features evident on echocardiography and computed tomography. Metronomic chemotherapy utilizing toceranib phosphate as well as medications for congestive heart failure were administered. During the period chemotherapy was administered (nine months from the time of diagnosis), clinical improvement was noted without the development of any adverse effects. However, clinical signs recurred after chemotherapy was discontinued at the owner’s request. When the patient was reevaluated via computed tomography, it was found that the size of the mass had increased. The patient developed severe dyspnea secondary to recurrent pleural effusion and was euthanized 65 days after clinical signs reappeared. A necropsy was performed and the patient was definitively diagnosed with a chemodectoma based on histopathologic and immunohistochemical analysis. This case report describes the clinical application of metronomic chemotherapy with toceranib phosphate, which is a tyrosine kinase inhibitor, in the treatment of a chemodectoma. We propose that this treatment may improve the quality of life and result in a prolonged survival time compared to treatment with medications for congestive heart failure alone.

Congestive heart failure information extraction framework for automated treatment performance measures assessment.

This paper describes a new congestive heart failure (CHF) treatment performance measure information extraction system - CHIEF - developed as part of the Automated Data Acquisition for Heart Failure project, a Veterans Health Administration project aiming at improving the detection of patients not receiving recommended care for CHF. CHIEF is based on the Apache Unstructured Information Management Architecture framework, and uses a combination of rules, dictionaries, and machine learning methods to extract left ventricular function mentions and values, CHF medications, and documented reasons for a patient not receiving these medications. The training and evaluation of CHIEF were based on subsets of a reference standard of various clinical notes from 1083 Veterans Health Administration patients. Domain experts manually annotated these notes to create our reference standard. Metrics used included recall, precision, and the F 1 -measure. In general, CHIEF extracted CHF medications with high recall (>0.990) and good precision (0.960-0.978). Mentions of Left Ventricular Ejection Fraction were also extracted with high recall (0.978-0.986) and precision (0.986-0.994), and quantitative values of Left Ventricular Ejection Fraction were found with 0.910-0.945 recall and with high precision (0.939-0.976). Reasons for not prescribing CHF medications were more difficult to extract, only reaching fair accuracy with about 0.310-0.400 recall and 0.250-0.320 precision. This study demonstrated that applying natural language processing to unlock the rich and detailed clinical information found in clinical narrative text notes makes fast and scalable quality improvement approaches possible, eventually improving management and outpatient treatment of patients suffering from CHF.

Randomized pilot trial comparing tolvaptan with furosemide on renal and neurohumoral effects in acute heart failure.

AimsLoop diuretics are first‐line medications for congestive heart failure (CHF); however, they are associated with serious adverse effects, including decreased renal function, and sympathetic nervous and renin–angiotensin system activation. We tested whether tolvaptan, a vasopressin V2‐receptor antagonist, could reduce unfavourable furosemide‐induced effects during CHF treatment.Methods and resultsSixty patients emergently hospitalized owing to CHF‐induced dyspnea were randomly assigned to receive either 40 mg intravenous furosemide daily or 7.5 mg oral tolvaptan for 5 days after admission. Both groups also received intravenous carperitide and canrenoate potassium. As results, baseline patient characteristics were similar between the furosemide (n = 30) and the tolvaptan (n = 30) groups, with no significant difference in 5 day urine volume or fluid balance. Brain natriuretic peptide and body weight improvements were similar between groups. However, serum creatinine (Cr) level did not increase, and the incidence of worsening renal function was significantly lower in the tolvaptan group. Consequently, the Cr increase to gain 1000 mL urine was 2.5‐fold lower in the tolvaptan group. Furthermore, the blood urea nitrogen (BUN)/Cr ratio significantly decreased in the tolvaptan group, suggesting that renal perfusion was preserved, and urea reuptake and passive water reabsorption were suppressed following tolvaptan treatment. Although catecholamine improvements after treatment were not significantly different, plasma renin activity was enhanced in the furosemide group.ConclusionsAs compared with furosemide, tolvaptan in patients with acute heart failure is associated with comparable decongestion, better preservation of renal function and less activation of renin–angiotensin system. (UMIN 000014134).

Dilated Cardiomyopathy Induced by Chronic Starvation and Selenium Deficiency.

Protein energy malnutrition (PEM) has been rarely documented as a cause of cardiovascular abnormalities, including dilated cardiomyopathy. Selenium is responsible for antioxidant defense mechanisms in cardiomyocytes, and its deficiency in the setting of PEM and disease related malnutrition (DRM) may lead to exacerbation of the dilated cardiomyopathy. We report a rare case of a fourteen-year-old boy who presented with symptoms of congestive heart failure due to DRM and PEM (secondary to chronic starvation) along with severe selenium deficiency. An initial echocardiogram showed severely depressed systolic function consistent with dilated cardiomyopathy. Aggressive nutritional support and replacement of selenium and congestive heart failure medications that included diuretics and ACE inhibitors with the addition of carvedilol led to normalization of the cardiac function within four weeks. He continues to have significant weight gain and is currently completely asymptomatic from a cardiovascular standpoint.

Anticholinergic medications: an additional contributor to cognitive impairment in the heart failure population?

Patients with congestive heart failure (CHF) have a high prevalence of cognitive impairment and the association is multifactorial. In general, the burden of anticholinergic drugs has consistently been shown to be a risk factor for cognitive impairment in the elderly. The aim of this study was to assess the cognitive burden of medications in patients with CHF. This was a cross-sectional, retrospective, single-center study. The study was conducted in an outpatient setting. Patients who presented to a comprehensive heart failure clinic during a 1-month period were included. The primary outcomes of interest were mean anticholinergic cognitive burden (ACB) score of all medications and CHF medications (ACB-CHF), calculated based on the ACB Scoring Scale (ACB-SS). The ACB-CHF score was further dichotomized as 0 or 1 (low anticholinergic burden) versus 2 or 3 (high anticholinergic burden). A total of 182 patients were included. The mean ACB and ACB-CHF scores were 2.4 (range 0-13) and 1.0 (range 0-4), respectively, while 25.8 % of patients had an ACB-CHF score of 2 or 3. There was no association found between ejection fraction in patients with systolic heart failure and the ACB (p = 0.28) or ACB-CHF (p = 0.62) score. We conclude that patients with CHF have a substantial exposure to anticholinergic medications with adverse cognitive effects. This may be another important contributor to the increased prevalence of cognitive impairment in these patients.

Combined obstructive hypertrophic cardiomyopathy and double outlet right ventricle in an infant with Down syndrome

Patient: Male, 2Final Diagnosis: Obstructive hypertrophic cardiomyopathySymptoms: Congestive heart failureMedication: —Clinical Procedure: Left ventricular septal myectomy • repair of congenital heart diseaseSpecialty: CardiologyObjective:Rare diseaseBackground:Hypertrophic cardiomyopathy (HCM) is uncommon in Down syndrome (DS). When combined with congenital heart disease (CHD) both morbidity and mortality may be greater compared to CHD alone. Whether HCM in DS patients is related to having trisomy 21 versus a second site mutation is unknown.Case Report:We report a case of severe HCM in an infant with DS in combination with double outlet right ventricle (DORV) who required surgery for relive of sub-aortic obstruction and congestive heart failure. We predicted that this infant would have a second site mutation involving either a sarcomeric protein or metabolic disorder as a cause for his HCM. Using current genetic and metabolic testing as well as histologic assessment of excised cardiac tissue we sought to further characterize the nature of the HCM. A successful resection of sub-aortic stenosis and DORV repair was performed. Genetic and metabolic testing was negative for gene defects and/or syndromes commonly associated with familial HCM. Excised cardiac tissue from the ventricular septum exhibited myocyte hypertrophy and sub-endocardial fibrosis but no sarcomeric disarray, myocyte fibrosis or glycogen storage. Metabolic testing for common forms of mitochondrial disease was negative. Post-operative echocardiograms show persistent, non-obstructive septal hypertrophy.Conclusions:Unlike prior reports, this child required a surgical intervention to relieve his sub-aortic obstruction. Thus, HCM in this population can be more serious that previously suspected. Although testing did not reveal the cause of his HCM, we still suggest screening for known causes of HSC until the etiology of the HCM in DS is well understood.

Abstract P215: Primary Cardiology Service Versus Cardiology Consultation: Differences in Heart Failure Patients' Medication Regimens on Discharge

Introduction: Patients with congestive heart failure (CHF) exacerbation are increasingly admitted to a hospitalist service with a cardiology consultation (CC) versus a primary cardiology service (PCS). Our study investigates differences in discharge medication regimens, heart rate (HR) and blood pressure (BP) between these two groups. We hypothesize that PCS patients are more likely to be discharged with appropriate CHF medication regimens and have lower HR and BP. Methods: All patients admitted to Cooper University Hospital with CHF exacerbation from 9/1/03 to 8/30/05 were included. A total of 415 consecutive admissions were included. Demographic, past medical history, admission and discharge medication regimens, and discharge vital signs were collected. Chi-square analysis and student's t-test were used for statistical analysis. Results: Forty percent of our study population was female. The mean age was 65.9 years and forty five percent were White. Two thirds of patients were managed on a PCS. Both groups had 40% female patients and an average age of 65 years, however there were significantly more White patients on the PCS. Rates of atrial fibrillation, hypertension and diabetes mellitus were equivalent between the two groups. However, renal disease was more frequent in CC group. The mean length of stay was equivalent between both groups as was systolic function. PCS patients were more likely to be admitted with ACE inhibitors, diuretics and aldosterone inhibitors than CC patients. On discharge, PCS patients were more likely to be discharged with digoxin (p<0.01), diuretics (p<0.001), beta-blockers (p<0.05) and aldosterone antagonists (p<0.01). On discharge, PCS patients had lower HR (p<0.01) and BP (p<0.05) than CC patients. Conclusions: Our study shows that discharge medication regimens for CHF vary significantly between patients taken care under a PCS as compared to a CC service. We hypothesize by being on the PCS, patients are more frequently reassessed and thus have greater opportunities for inpatient medication adjustment. These medication regimen differences manifest in clinical vital sign changes upon discharge between the two groups. Further study is warranted to see if these differences from 5-7 years ago continue to the present day.

Zinc and Copper Levels in Severe Heart Failure and the Effects of Atrial Fibrillation on the Zinc and Copper Status

Oxidative stress is involved in the pathogenesis of congestive heart failure (CHF). Some trace elements serve as antioxidant defenses. The purpose of this study was to analyze the effect of atrial fibrillation (AF) on zinc (Zn) and copper (Cu) levels in patients with advanced CHF. In this prospective study, serum Zn and Cu levels in 78 patients with clinically advanced CHF, i.e., New York Heart Association (NYHA) functional class III or IV (40 patients with AF and 38 in sinus rhythm) were measured using atomic absorption spectrophotometry. All patients also had a left ventricular ejection fraction (EF) of <35%. We recruited 40 volunteers with nearly the same age and weight as control. They had normal EF. There was no significant difference between patients with AF and those with sinus rhythm regarding serum Zn and Cu levels. However, both groups showed significant hypozincemia (p < 0.000) and a decreased Zn/Cu ratio (p < 0.03) compared with control group. Serum Cu levels were similar in the two groups and did not differ significantly from the control group. In patients with advanced CHF, irrespective of the rhythm, profound hypozincemia, and a decreased Zn/Cu ratio were present, which could be secondary to the activation of the renin-angiotensin-aldosterone system and CHF medications. The results suggest the need for more studies focusing on possible benefits with Zn nutriceutical replacement in patients with advanced CHF.

A Case of Yellow Nail Syndrome: Misdiagnosis as Congestive Heart Failure

Yellow nail syndrome (YNS) is a rare disorder of unknown cause associated with yellow nails, lymphedema and respiratory manifestations. It was first described by Samman and White in 1964, and to date, approximately 150 cases have been reported. The diagnosis of YNS is essentially a clinical one and based on the presence of characteristic findings. We report a case of YNS of a 62-year-old female who presented with a 4-month history of dyspnea and recurrent pleural effusion. The patient had a 5-year history of leg swelling and dyspnea. She had been managed with medications for congestive heart failure (CHF) for two years and she was referred to our hospital for further evaluation and management.

The Role of Anemia in the Progression of Congestive Heart Failure: Is There a Place for Erythropoietin and Intravenous Iron?

SUMMARY Despite all the advances in congestive heart failure (CHF), the mortality, morbidity and the number of rehospitalizations in this condition is still very high, even if patients are given the recommended CHF medications in the recommended doses.We found that the majority of these refractory CHF patients were anemic, with hemoglobin concentrations less than 12 g/dL. In both uncontrolled and controlled studies, when we corrected their anemia with subcutaneous erythropoietin (EPO) and intravenous iron sucrose, we found that their cardiac functional status and cardiac function improved, their need for rehospitalization fell dramatically and their need for diuretics improved greatly. Their renal function, which had been deteriorating rapidly before correction of the anemia, generally stabilized or improved. Others subsequently found, in controlled studies using EPO, that cardiac function, as judged by oxygen utilization during peak exercise, also improved, as did exercise capacity and quality of life. Subsequently, many others have examined this relationship of anemia to the severity of CHF, the mortality rate and the hospitalization rate, and the great majority have confirmed our findings. A randomized controlled double-blind study is now being carried out on hundreds of severe, anemic CHF patients to ascertain the role of anemia correction is in CHF. If it verifies the preliminary optimistic results mentioned above, anemia management may become an important new therapy for the prevention of progression of CHF and the associated renal failure.

Utilization of, and Adherence to, Drug Therapy Among Medicaid Beneficiaries with Congestive Heart Failure

Background: Congestive heart failure (CHF) affects 4.8 million adult Americans, particularly those aged >65 years, and has been described as a “new epidemic” due to the high annual incidence of the disease (an estimated 550,000 new cases per year). Objectives: The goal of this research was to determine the number of Medicaid beneficiaries with CHF, identify the rate of CHF drug use, estimate adherence rates, examine factors associated with CHF drug use and adherence, and explore policy implications of the research findings. Methods: Methods used included identifying noninstitutionalized beneficiaries with >1 inpatient claim or ≥2 ambulatory claims with a CHF diagnosis and claims for CHF drugs using 1998 State Medicaid Research Files and 1999 Medicaid Analytic eXtract data for Arkansas, California, Indiana, and New Jersey. Patient adherence was estimated using the medication possession ratio (MPR) and days of medication persistence. Multivariate regression models were used to identify factors associated with CHF drug use and adherence. Results: Overall, 84.8% of beneficiaries had claims for at least 1 CHF medication; 15.2% of beneficiaries were not using any CHF medications. Among those with a claim, the mean number of claims per month was 1.4, and 25.8% had ≥4 claims per month. Mean MPR was 71.9% and mean days of medication persistence were 24.8 per month. Persons aged <65 years, men, ethnic minorities, patients with hospital admissions for conditions other than CHF, and beneficiaries with high Chronic Illness and Disability Payment System scores were less likely to have a CHF drug claim and had lower adherence rates. Conclusions: State Medicaid agencies and Medicare prescription drug plans should consider designing targeted interventions that encourage better adherence among Medicaid beneficiaries with CHF, particularly men, those aged <65 years, ethnic minorities, and patients with poor overall health status. ( Clin Ther. 2007;29:1771-1783) Copyright © 2007 Excerpta Medica, Inc.

Dilated Cardiomyopathy Following Right Ventricular Pacing for AV Block in Young Patients: Resolution After Upgrading to Biventricular Pacing Systems

Cardiac resynchronization therapy (CRT) has been demonstrated to result in clinical improvement in older adult patients with dilated cardiomyopathy (DCM), specifically those with left bundle branch block and prolonged QRS duration. We sought to demonstrate the benefits of CRT on improvement in cardiac function and clinical outcome in young patients that developed congestive heart failure (CHF) and DCM following cardiac pacing for AV block. We reviewed the charts of six patients who developed CHF or low cardiac output symptoms and DCM following implantation of right ventricular (RV)-based pacing systems for AV block, and subsequently underwent CRT. Patients ranged in age from 6 months to 23.7 years (mean: 11.3 +/- 3.6 years). AV block was congenital (3), post-surgery (2), and acquired (1). Pacing had been performed for 0.1-14.5 (7.6 +/- 2.4) years prior to development of DCM. Two patients required listing for cardiac transplantation. Following CRT: (1) QRS duration shortened from 204 +/- 15 to 138 +/- 10 msec, P = 0.002, (2) left ventricular ejection fraction improved from 34 +/- 6 to 60 +/- 2%, P = 0.003, and (3) left ventricular end diastolic dimension shortened from 5.5 +/- 0.8 to 4.3 +/- 0.5 cm, P = 0.03. All patients demonstrated clinical improvement and have been weaned from CHF medications and listing for cardiac transplantation. CRT can benefit young patients that develop CHF and DCM following RV pacing for AV block. Upgrading to biventricular pacing systems should be considered early in the management of these patients prior to listing for cardiac transplantation.

Erythropoietin in Heart Failure

The incidence of both congestive heart failure (CHF) and end-stage renal disease both are increasing. Anemia is common in both conditions and is associated with a marked increase in mortality and morbidity in both CHF and chronic kidney insufficiency (CKI). Each of these 3 conditions can cause or worsen the other 2. In other words, a vicious circle frequently is present in which CHF can cause or worsen both anemia and CKI, in which CKI can cause or worsen both anemia and CHF, and in which anemia can cause or worsen both CHF and CKI. We have called this vicious circle the cardio renal anemia syndrome. Optimal treatment of CHF with all the recommended CHF medications at their recommended doses will, in our experience, frequently fail to improve the CHF and CKI if anemia is present and is not corrected. On the other hand, correction of the anemia with subcutaneous erythropoietin and intravenous iron has caused a great improvement in the CHF including a marked improvement in patient and cardiac function and a marked reduction in the need for hospitalization and for high-dose diuretics. It also frequently has caused renal function to improve or at least stabilize. In addition, patients' quality of life and exercise capacity also have improved with the correction of the anemia. In CKI patients, anemia also may play an important role in increasing the risk for death, coronary heart disease, stroke, and progression to end-stage renal disease. Erythropoietin may have a direct positive effect on the heart and brain unrelated to correction of the anemia by reducing cell apoptosis and by increasing neovascularization, both of which could prevent tissue damage. This could have profound therapeutic implications not only in CHF but in the future treatment of myocardial infarction, coronary heart disease, strokes, and renal failure.

Predictors of medication refill–seeking behavior in the ED

Objective Determine predictors of medication refill–seeking behavior in ED patients with chronic illness. Methods/Design Prospective cross-sectional ED survey conducted for 6 weeks. Setting Public hospital ED (>140 000 visits per year). Subjects ED patients (>18 years) taking chronic medications for congestive heart failure, diabetes, and/or hypertension. Results Of 1168 patients surveyed, 344 (29%) presented to the ED secondary to running out of medications and requiring a medication refill. Univariate predictors included age younger than 50 years, non-Hispanic ethnicity, low income (<US$5000 per year), self-pay payor status, and being told to call a primary care physician before medication would be refilled. Lack of knowledge about refill or pharmacy numbers on the medication bottle resulted in patients being more than twice as likely to be in the ED for a medication refill (odds ratio 2.4 [1.6, 3.6] and 2.0 [1.3, 2.9], respectively). Conclusion Presenting for medication refills is common in ED patients with chronic illness.

Splicing mutation in the fibrillin‐1 gene associated with neonatal Marfan syndrome and severe pulmonary emphysema with tracheobronchomalacia

Neonatal Marfan syndrome is an autosomal-dominant connective tissue disease with unique clinical manifestations and mutations. We describe the clinical course of an infant with neonatal Marfan syndrome that had the novel IVS31-2A > G splice site mutation in fibrillin-1. This mutation affects the second base of the acceptor consensus splice site of intron 31, and probably leads to abnormal splicing events. The patient presented with respiratory distress and heart murmur in early neonatal life. Cardiac evaluation revealed pulmonic stenosis, atrioventricular regurgitation, and a dilated aortic root that were controlled by balloon dilatation of the pulmonic stenosis and medications for congestive heart failure. At age 3 months, he presented with severe respiratory distress caused by upper and lower airway obstruction. Imaging studies showed severe pulmonary emphysema, and a bronchoscopy demonstrated megatracheobronchomalacia, an unusual finding in this syndrome. Subsequently, the patient developed recurrent hyperinflation of the right and left lungs, with emphysematous changes and mediastinal shift. After discussing with his parents the grave prognosis for neonatal Marfan syndrome, he was discharged home with oxygen treatment and died at home at age 4.5 months. This case report demonstrates and discusses pulmonary involvement in neonatal Marfan syndrome and the difficult therapeutic challenges created by the severe cardiopulmonary abnormalities in this invariably fatal condition.

Association of medication adherence, knowledge, and skills with emergency department visits by adults 50 years or older with congestive heart failure

The association of medication adherence, knowledge, and skills with emergency department (ED) visits by patients 50 years of age or older with congestive heart failure (CHF) was studied. The patients in this study were enrolled in the usual care group of an ongoing trial of patients with CHF to determine the effects of a pharmacy-based intervention on relevant outcomes. Participants' medication knowledge and skills were assessed during individual interviews. Medication knowledge assessed patients' knowledge of the dosage, frequency, and indication of each of their CHF medications. The medications skills assessment evaluated patients' dexterity (ability to open medication bottles), literacy (ability to read labels), and ability to distinguish colors of tablets and capsules. Medication adherence to CHF drugs was calculated from electronic monitors and prescription-refill records over a six-month period. The primary outcomes of this study were the numbers of all-cause cardiovascular and CHF-specific ED visits during a six-month period. Log-linear regression models were used to analyze the effects of medication knowledge, skill, and adherence on ED visits. Sixty-one patients participated in this study. Multivariate log-linear models adjusted for demographic variables showed that lower medication adherence (p < 0.001) and an inability to read standard prescription and auxiliary labels (p = 0.002) were associated with an increased number of cardiovascular-related ED visits. Knowledge of the prescribed dose was associated with CHF-specific ED visits (p < 0.001). Greater medication knowledge, skills, and adherence were associated with fewer ED visits among patients 50 years of age or older with CHF in an urban, teaching medical center.

“Fill ‘Er Up!” in the pharmacy of last resort: predictors of refill-seeking behavior in the emergency department

Study objectives: We determine predictors of medication refill-seeking behavior in emergency department (ED) patients with chronic illness. Methods: This was a prospective, cross-sectional ED survey of chronic medication use in a large public hospital ED (>140,000 visits/year) during a 6-week period. Adult ED patients (>18 years) taking chronic medications for congestive heart failure, diabetes mellitus, or hypertension were included. Results: Of 1,168 patients approached, none refused participation; 344 (29%) presented to the ED after running out of medications. Significant univariate predictors of being in the ED for a medication include age younger than 50 years, non-Hispanic ethnicity, low income ( P Conclusion: Presenting for medication refills is common in ED patients with chronic illness; especially for those who are younger, uninsured, on a limited income, and unaware of common medication refill practices.

Erythropoietin should be part of congestive heart failure management: Management of comorbidities in kidney disease in the 21st century: Anemia and bone disease

Up to 64% of patients referred to nephrologists with chronic kidney insufficiency (CKI) have evidence of congestive heart failure (CHF), and most of these patients are also anemic. We have called this triad of anemia, CKI, and CHF the cardio renal anemia (CRA) syndrome. The 3 components of this syndrome form a vicious circle, with each one capable of causing or worsening the other 2. Anemia is found in one-third to one-half of CHF patients and can either cause or worsen the CHF, and can increase the mortality, hospitalization, and malnutrition in this condition. Anemia is also associated with a worsening of renal function in CHF and CKI, causing a more rapid progression to dialysis than is found in those without anemia. Uncontrolled CHF can cause rapid deterioration of renal function and may also cause anemia. Chronic kidney insufficiency can cause anemia and worsen the CHF. Aggressive therapy of CHF with all the accepted CHF medications in the accepted doses will often fail to improve the CHF if anemia is also present but is not corrected. However, when the anemia was corrected with subcutaneous erythropoietin and, in some cases, with intravenous iron, the cardiac and patient function and quality of life improved, the need for hospitalization and for high-dose oral and intravenous diuretics was strikingly reduced, and renal function, which had previously been deteriorating, stabilized. Nephrologists should carefully assess the cardiac status of all CKI patients, including routinely getting an echocardiogram and possibly measuring B-type natriuretic peptide. Where CHF is present, the indicated CHF agents in the indicated doses should be used. Studies show that most cardiologists and internists do not recognize, investigate, or treat the anemia frequently seen in their CHF patients. In our experience cooperation between nephrologists and these specialists has increased their awareness about anemia, resulting in its earlier correction, and thus preventing the deterioration of the CHF, the CKI, and the anemia itself.