Prescription Of Medical Therapy Research Articles

Barriers to adherence to secondary prevention therapy in patients with ischemic heart disease: a cross-sectional study of a Mexican reference center.

This article aims to assess the adherence level to second-line therapy for cardiovascular prevention in a tertiary hospital in Mexico City and identify key barriers to adequate pharmacological adherence. A single-center prospective cross-sectional study was conducted between August 2018 and February 2020. Sociodemographic data were collected, and the Morisky medication adherence scale was performed. Directed interviews during medical consultations were also conducted to determine reasons for non-adherence. Showed that out of 991 patients included with a median age of 65 (58.72) years, 70.3% exhibited inadequate adherence, with forgetfulness being the most common reason (55.4%). Patients receiving combined therapy with coronary revascularization showed higher adherence compared to those on optimal medical therapy alone. Low educational level (OR 1.68, IC 95% 1.23-2.23, p = 0.0001) and the use of optimal medical therapy alone (OR 1.2, I 95% 1.11-2.007 p = 0.007) were identified as predictors of poor adherence. Among patients with ischemic heart disease and pharmacological therapy for secondary prevention, inadequate adherence is observed in 70% of cases. Factors associated with poor pharmacological adherence were low educational level and prescription of medical therapy without revascularization.

Digital solutions to optimize guideline-directed medical therapy prescription rates in patients with heart failure: a clinical consensus statement from the ESC Working Group on e-Cardiology, the Heart Failure Association of the European Society of Cardiology, the Association of Cardiovascular Nursing & Allied Professions of the European Society of Cardiology, the ESC Digital Health Committee, the ESC Council of Cardio-Oncology, and

The 2021 European Society of Cardiology guideline on diagnosis and treatment of acute and chronic heart failure (HF) and the 2023 Focused Update include recommendations on the pharmacotherapy for patients with New York Heart Association (NYHA) class II-IV HF with reduced ejection fraction. However, multinational data from the EVOLUTION HF study found substantial prescribing inertia of guideline-directed medical therapy (GDMT) in clinical practice. The cause was multifactorial and included limitations in organizational resources. Digital solutions like digital consultation, digital remote monitoring, digital interrogation of cardiac implantable electronic devices, clinical decision support systems, and multifaceted interventions are increasingly available worldwide. The objectives of this Clinical Consensus Statement are to provide (i) examples of digital solutions that can aid the optimization of prescription of GDMT, (ii) evidence-based insights on the optimization of prescription of GDMT using digital solutions, (iii) current evidence gaps and implementation barriers that limit the adoption of digital solutions in clinical practice, and (iv) critically discuss strategies to achieve equality of access, with reference to patient subgroups. Embracing digital solutions through the use of digital consults and digital remote monitoring will future-proof, for example alerts to clinicians, informing them of patients on suboptimal GDMT. Researchers should consider employing multifaceted digital solutions to optimize effectiveness and use study designs that fit the unique sociotechnical aspects of digital solutions. Artificial intelligence solutions can handle larger data sets and relieve medical professionals' workloads, but as the data on the use of artificial intelligence in HF are limited, further investigation is warranted.

Abstract P156: Insurance Impact on Guideline-Directed Medical Therapy Prescription in HIV Heart Failure Patients: Past vs. Present Data From New York City's Largest Public Healthcare System

Introduction: Guideline-Directed Medical Therapy (GDMT), comprising renin-angiotensin system inhibitors, evidence-based β-blockers, mineralocorticoid inhibitors, and sodium glucose cotransporter 2 inhibitors, significantly enhances patient survival in heart failure cases. However, the impact of public insurance, private coverage, and being uninsured on GDMT for HIV heart failure patients is understudied. This research compares GDMT prescriptions across various insurance types over time. Method: This study analyzed data from the New York City Health + Hospitals HIV Heart Failure (NYC 4H) retrospective cohort, comprising records from eleven major NYC Health + Hospitals. Patients were recruited from hospital visits, both inpatient and clinic, spanning from July 2017 to June 2022. Follow-up records were reviewed between July 2022 and August 2023. Insurance types were determined based on primary insurance coverage in the medical charts. Guideline-directed medical therapy (GDMT) was reviewed at baseline and follow-up encounter. Insurance coverage and GDMT prescriptions were compared using chi-square tests. Multivariable logistic regression models, adjusted for age, sex, race, and co-morbidities, were employed to observe the association between insurance and GDMT prescriptions. Result: A total of 726 HIV heart failure patients participated in the study, including 263 with Medicare, 334 with Medicaid, 96 with private insurance, and 33 without insurance. Significant difference in GDMT prescriptions were evident at baseline, with >1 and >2 GDMT prescriptions being higher among uninsured (69.7% and 36.4%) and Medicare (66.2% and 37.6%) patients compared to Medicaid (54.8% and 29.9%) and private insurance patients (55.2% and 20.8%) (P<0.05). Private insurance holders exhibited a 49% lower likelihood of receiving >2 GDMT prescriptions than Medicare beneficiaries after adjusting for age, sex, race, and co-morbidities (adjusted odds ratio [aOR] 0.51, 95% confidence interval [CI] [0.28, 0.93], p<0.05). Over the four-year follow-up, prescription rates for GDMT medications notably increased. However, disparities persisted in >1 and >2 GDMT prescriptions across insurance types, including 90.9% and 51.5% for uninsured, 76% and 48.3% for Medicare, 72.8% and 45.2% for Medicaid, and the lowest rates of 66.7% and 35.4% for private insurance patients, respectively (P<0.05). After adjusting for covariates, no statistically significant differences in GDMT prescriptions were found across insurance type. Conclusion: GDMT prescriptions significantly improved over the follow-up period within HIV heart failure population. Although the differences diminished slightly, private insurance beneficiaries consistently exhibited the lowest GDMT prescription rates at both baseline and follow-up, in comparison to Medicare, Medicaid, and the uninsured population.

Impact of myocardial perfusion and coronary calcium on medical management for coronary artery disease.

Single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) remains one of the most widely used imaging modalities for the diagnosis and prognostication of coronary artery disease (CAD). Despite the extensive prognostic information provided by MPI, little is known about how this influences the prescription of medical therapy for CAD. We evaluated the relationship between MPI with computed tomography (CT) attenuation correction and prescription of acetylsalicylic acid (ASA) and statins. We performed a retrospective analysis of consecutive patients who underwent SPECT MPI at a single centre between 2015 and 2021. Myocardial perfusion abnormalities and coronary calcium burden were assessed, with attenuation correction imaging 77.8% of patients. Medication prescriptions before and within 180 days after the test were compared. Associations between abnormal perfusion and calcium burden with ASA and statin prescription were assessed using multivariable logistic regression. In total, 9908 patients were included, with a mean age 66.8 ± 11.7 years and 5337 (53.9%) males. The prescription of statins increased more in patients with abnormal perfusion (increase of 19.2 vs. 12.0%, P < 0.001). Similarly, the presence of extensive CAC led to a greater increase in statin prescription compared with no calcium (increase 12.1 vs. 7.8%, P < 0.001). In multivariable analyses, ischaemia and coronary artery calcium were independently associated with ASA and statin prescription. Abnormal MPI testing was associated with significant changes in medical therapy. Both calcium burden and perfusion abnormalities were associated with increased prescriptions of medical therapy for CAD.

The Effects of Post-Acute Care in Patients with Heart Failure in Taiwan: A Single Center Experience.

The National Health Insurance Administration in Taiwan has promoted the heart failure post-acute care (HF-PAC) program as a means to provide proactive integrated care within the optimal treatment timeframe to enhance functional recovery after acute decompensated heart failure (HF). The aim of this program was to reduce HF readmission rates, improved medication prescription rates, and improve the quality of life in HF patients. Patients who had a reduced left ventricular ejection fraction (LVEF) of ≤ 40% were included and followed up for 6 months after discharge. They underwent cardiac rehabilitation and physiological, and nutritional status evaluations. The main clinical outcomes of the HF-PAC program were guideline-directed medical therapy prescription rate and 6-month readmission rate. A total of 122 patients were recruited from June 2018 to December 2020 at a medical center in southern Taiwan. The patients' activities of daily living, nutritional status, quality of life and LVEF were significantly improved during the HF-PAC program. More than 95% of the patients received guideline-directed medical prescriptions at the end of the HF-PAC program. The cardiovascular-related 6-month re-admission rate after the HF-PAC program ended was 27.7%, and it could be predicted by the New York Health Association functional class [hazard ratio (HR) 95% confidence interval (95% CI) = 4.12 (1.36-12.46)], value of the Mini Nutritional Assessment - Short Form [HR (95% CI) = 0.46 (0.31-0.68)] and LVEF [HR (95% CI) = 0.95 (0.91-0.99)]. By incorporating multidisciplinary healthcare teams, the HF-PAC program improves the guideline- directed medical therapy prescription rate, thus improving patients' cardiac function, physical activity recovery, the quality of life, and also reduces their readmission rate.

Electronic Alerts to Improve Heart Failure Therapy in Outpatient Practice: A Cluster Randomized Trial

BackgroundThe use of guideline-directed medical therapy (GDMT) is underprescribed in patients with heart failure with reduced ejection fraction (HFrEF). ObjectivesThis study sought to examine whether targeted and tailored electronic health record (EHR) alerts recommending GDMT in eligible patients with HFrEF improves GDMT use. MethodsPROMPT-HF (PRagmatic trial Of Messaging to Providers about Treatment of Heart Failure) was a pragmatic, EHR-based, cluster-randomized comparative effectiveness trial. A total of 100 providers caring for patients with HFrEF were randomized to either an alert or usual care. The alert notified providers of individualized GDMT recommendations along with patient characteristics. The primary outcome was an increase in the number of GDMT classes prescribed at 30 days postrandomization. Providers were surveyed on knowledge of guidelines and user experience. ResultsThe study enrolled 1,310 ambulatory patients with HFrEF from April to October 2021. Median age was 72 years; 31% were female; 18% were Black; and median left ventricular ejection fraction was 32%. At baseline, 84% of participants were receiving β-blockers, 71% received a renin-angiotensin-aldosterone system inhibitor, 29% received a mineralocorticoid receptor antagonist, and 11% received a sodium-glucose cotransporter-2 inhibitor. The primary outcome occurred in 176 of 685 (26%) participants in the alert arm vs 117 of 625 (19%) in the usual care arm, thus increasing GDMT class prescription by >40% after alert exposure (adjusted relative risk: 1.41; 95% CI: 1.03-1.93; P = 0.03). The number of patients needed to alert to result in an increase in addition of GDMT classes was 14. A total of 79% of alerted providers agreed that the alert was effective at enabling improved prescription of medical therapy for HF. ConclusionsA real-time, targeted, and tailored EHR-based alerting system for outpatients with HFrEF led to significantly higher rates of GDMT at 30 days when compared with usual care. This low-cost intervention can be rapidly integrated into clinical care and accelerate adoption of high-value therapies in heart failure. (PRagmatic trial Of Messaging to Providers about Treatment of Heart Failure [PROMPT-HF; NCT04514458])

Virtual optimization of guideline-directed medical therapy in hospitalized patients with heart failure with reduced ejection fraction: the IMPLEMENT-HF pilot study.

Implementation of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) remains incomplete. Non-cardiovascular hospitalization may present opportunities for GDMT optimization. We assessed the efficacy and durability of a virtual, multidisciplinary 'GDMT Team' on medical therapy prescription for HFrEF. Consecutive hospitalizations in patients with HFrEF (ejection fraction ≤40%) were prospectively identified from 3 February to 1 March 2020 (usual care group) and 2 March to 28 August 2020 (intervention group). Patients with critical illness, de novo heart failure, and systolic blood pressure <90 mmHg in the preceeding 24 hs prior to enrollment were excluded. In the intervention group, a pharmacist-physician GDMT Team provided optimization suggestions to treating teams based on an evidence-based algorithm. The primary outcome was a GDMT optimization score, the sum of positive (+1 for new initiations or up-titrations) and negative therapeutic changes (-1 for discontinuations or down-titrations) at hospital discharge. Serious in-hospital safety events were assessed. Among 278 consecutive encounters with HFrEF, 118 met eligibility criteria; 29 (25%) received usual care and 89 (75%) received the GDMT Team intervention. Among usual care encounters, there were no changes in GDMT prescription during hospitalization. In the intervention group, β-blocker (72% to 88%; P=0.01), angiotensin receptor-neprilysin inhibitor (6% to 17%; P=0.03), mineralocorticoid receptor antagonist (16% to 29%; P=0.05), and triple therapy (9% to 26%; P < 0.01) prescriptions increased during hospitalization. After adjustment for clinically relevant covariates, the GDMT Team was associated with an increase in GDMT optimization score (+0.58; 95% confidence interval +0.09 to +1.07; P=0.02). There were no serious in-hospital adverse events. Non-cardiovascular hospitalizations are a potentially safe and effective setting for GDMT optimization. A virtual GDMT Team was associated with improved heart failure therapeutic optimization. This implementation strategy warrants testing in a prospective randomized controlled trial.

Optimal Medical Therapy Prescription in Patients with Acute Coronary Syndrome in the Netherlands: A Multicenter Pilot Registry.

BackgroundUnlike neighboring countries, the Netherlands does not have a national acute coronary syndrome (ACS) registry to evaluate quality of care.ObjectiveWe conducted a pilot registry in two hospitals to assess the prescription of guideline-recommended therapies in Dutch patients with ACS.MethodsWe included all consecutive patients with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) (n = 1309) admitted to two Dutch percutaneous coronary intervention centers between March 2015 and February 2016. We collected follow-up medication use and reasons for discontinuation at discharge and 1, 6, and 12 months post-discharge. We assessed the use of optimal medical therapy (OMT), defined as the combined prescription of aspirin, P2Y12 inhibitors, statins, β-blockers, and angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers.ResultsOMT prescription was 43.2% at discharge, 60.1% at 1 month, and 28.7% at 12 months. At 1 month, OMT prescription was significantly lower in patients with NSTEMI (51.8 vs. 65.7% for STEMI; p < 0.001). OMT prescription was lower in women (6 months: 55.4 vs. 62.0%, p = 0.036) and in elderly patients.ConclusionIn this pilot study that aimed to extend a national Dutch ACS registry to patients with STEMI and NSTEMI, OMT prescription was comparable to that in other local registries, was lower in women and patients with NSTEMI, and decreased with increasing age.Electronic supplementary materialThe online version of this article (10.1007/s40256-020-00427-9) contains supplementary material, which is available to authorized users.

SEX-SPECIFIC DIFFERENCES IN RISK FACTORS AND THEIR CORRELATION IN PATIENTS WITH ESSENTIAL HYPERTENSION (STAGE III)

Aim.This paper is aimed at identifying risk factors (RFs) and assessing their correlation in men and women with essential hypertension (stage III) under medical treatment.Materials and methods.Ninety-eight patients (45 men and 53 women) with essential hypertension (stage III) were examined. All of them were divided into two groups by sex. Both groups were studied for risk factors (age, disease duration, body mass index), as well as the following indicators: blood lipids; blood glucose; total bilirubin and its fractions; alanine aminotransferase (ALT); aspartate aminotransferase (AST); blood creatinine with the calculation of glomerular filtration rate (GFR) using MDRD and CKD-EPI equations.Results.Sex-specific differences in RFs and their correlation in patients with essential hypertension (stage III) are presented. The frequency of comorbid pathology and associated conditions, as well as the amount of medication used by men and women is shown.Conclusion.Women are diagnosed with essential hypertension 4 years earlier; BMI values correspond to Class 1 obesity; GFR level corresponds to Stage 3 of chronic kidney disease; whereas men have higher levels of direct bilirubin, ALT and blood creatinine. Comorbid pathology is significantly more common in women, with diabetes mellitus being the most commonly detected such a pathology. The risk factor correlation in men and women is different, having a statistically significant multidirectional correlative relationship. All of the considered issues require further systematic study, as well as a rational approach to the prescription of medical therapy and the risk factor correction, taking the patient’s sex into account.

Abstract 251: Gender Equity in Rates of Guideline-Directed Medical Therapy Prescription at Discharge for Hospitalized Heart Failure Patients

Background: Heart failure (HF) is an increasingly prevalent condition with significant morbidity and mortality. Guideline-directed medical therapy (GDMT) reduces morbidity and mortality in heart failure with reduced ejection fraction, but continues to be under-prescribed. There is a paucity of data on the impact of patient gender on the quality of HF care, although it has previously been shown that women with other cardiovascular conditions, such as coronary artery disease, receive less intensive treatment. We sought to determine whether there is a difference in rates of prescription of GDMT for patients hospitalized with heart failure by gender with the hypothesis that rates of GDMT prescription in women would be lower than that in men. Methods: Over a six month study window, we identified 246 patients discharged from an urban academic medical center with a primary discharge diagnosis of systolic heart failure. Systematic chart review was performed to identify whether patients were discharged with the following medications: angiotensin converting enzyme inhibitor (ACE-I), angiotensin receptor blocker (ARB), beta blocker (BB), mineralocorticoid receptor antagonist (MRA), hydralazine and a nitrate, and neprilysin inhibitor/ARB. Statistical analysis was performed to evaluate for an association between rates of GDMT prescription and gender. Regression analysis was then performed to adjust for age, weight, serum potassium, and 1/(discharge creatinine). Results: At the time of discharge, there was no statistically significant difference in the rate of GDMT prescription for females compared to males in either the unadjusted or adjusted models. ACE-I or ARB prescription rates were 59% in females and 50% in males (p=0.11); BB prescription rates were 89% in females and 84% in males (p=0.27); MRA prescription rates were 43% in females and 52% in males (p=0.19). Prescription rates of combination therapy of ACE-I or ARB with BB and MRA were 30% in females and 31% in males (p=0.78). There was a significant difference in 30 day all-cause unadjusted readmission rates in females (22%) compared to males (37%) (p&lt;0.05). Conclusions: In this sample of hospitalized heart failure patients, no difference was found in rates of GDMT prescription for women as compared to men. Readmission rates were significantly higher for men than women, consistent with national data. Further investigation will determine the extent to which equity in prescription rates translates into improved outcomes for women hospitalized with heart failure.

Trends in optimal medical therapy prescription and mortality after admission for acute coronary syndrome: a 9-year experience in a real-world setting.

Optimal medical therapy (OMT) is recommended in acute coronary syndrome (ACS) patients. Few studies present temporal trends of OMT prescription and its impact on outcomes in a real-world setting. We aimed to evaluate OMT prescription in a real-world ACS population and its relation to mortality during almost a decade. Consecutive ST-elevation myocardial infarction and non-ST-elevation myocardial infarction (NSTEMI) patients (n = 9202) admitted to a single Dutch tertiary hospital between 2006 and 2014 were included and followed for drug prescription and mortality up to 1 year. Optimal medical therapy was defined as prescription of aspirin, P2Y12inhibitors, statin, beta-blockers, and angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEi/ARB). Optimal medical therapy prescription was 43.7% at discharge, 46.6% at 30-days, and 25.5% at 1-year. Optimal medical therapy prescription at discharge was lower among NSTEMI patients (34.5% vs. 49.2%, P < 0.001). Optimal medical therapy prescription at discharge, 30-days and 1-year and mortality outcomes did not change during the study period. After adjustment for baseline and admission characteristics, OMT at discharge was associated with a reduction in mortality in patients who survived hospitalization for the index event [adjusted hazard ratio: 0.66, 95% confidence interval (0.46-0.93)]. In this single-centre observational registry with >9000 patients reflecting almost a decade of ACS care, <50% of patients were on OMT at discharge. Prescription of OMT and mortality outcomes remained stable during the study period. After adjustment, OMT prescription at discharge was associated with reduced mortality in ACS survivors. Further contemporary randomized studies are warranted to determine the role of beta-blockers and ACEi/ARBs in ACS patients with preserved left ventricular ejection fraction.

CD4+ and CD8+ T‐lymphocyte scores cannot reliably predict progression in patients with benign prostatic hyperplasia

To determine whether the density of CD4(+) and CD8(+) T-lymphocytes in a transrectal ultrasonography (TRUS) biopsy of the prostate can be used to predict the progression of lower urinary tract symptoms (LUTS) in benign prostatic hyperplasia (BPH). In total, 100 patients were randomly selected from a pool of patients with histologically proven, benign TRUS biopsy specimens. There were seven full years of follow-up available. Clinical data were recorded, including prostate volume, International Prostate Symptom Score (IPSS), prostate-specific antigen, urine flow rate, postvoid residual urine volume and previous prostate surgery. Markers of disease progression included the subsequent development of acute urinary retention (AUR), ≥4 point rise in IPSS, prescription of medical therapy (α-blocker or 5-α-reductase inhibitor) and bladder outlet surgery. Four patients' specimens were unsuitable for analysis. Biopsy sections from 96 patients were immunohistochemically stained for the presence of CD4(+) and CD8(+) T-lymphocytes and the density of infiltrate was assessed using random field sampling and point counting. Some 29% of patients (28/96) did not have BPH at the time of biopsy. Of all patients, 41% (39/96) progressed, 10% of whom (4/39) did not have BPH at the time of biopsy. A further 10% (10/96) developed AUR, 7% (7/96) had a ≥4 point rise in IPSS, 33% (32/96) required medical therapy for BPH and 11% (11/96) required bladder outlet surgery. There was low correlation between CD4(+) and CD8(+) densities in paired sections. CD4(+) and CD8(+) densities did not provide any significant predictive function in the progression of BPH, nor was their any predictive association noted between CD4(+) and CD8(+) scores and the development of prostate cancer. Sub-analysis did show that a threshold mean of ≥1.35 CD8(+) cells per field predicted progression to AUR with a sensitivity of 60% (95% confidence interval, CI, 26.2-87.8), specificity of 73.3% (95% CI 62.6-82.2) but a positive predictive value of 20.6% (95% CI 8.0-39.7). CD4(+) infiltrate density suggested a trend to general progression but without statistical significance. The present study, despite certain trends, shows no evidence for an association between CD4(+) and CD8(+) T-lymphocytes and the progression of LUTS in BPH.