Compliance with clinical practice guidelines for the treatment and optimization of therapy in heart failure patients in outpatient medicine clinics

MaryAnn E. Birch, Pharm.D., Emily K. McCoy, Pharm.D., Bradley M. Wright, Pharm.D., BCPS, Kristi Kelley, Pharm.D., BCPS, CDE

• The American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) clinical guidelines address the pharmacological treatment of heart failure (HF)

• Beta blockers and angiotensin converting enzyme inhibitors (ACEi) are recommended if patients have:– Current or prior symptoms of HF – Ejection fraction (EF) less than 40 percent– No contraindications

• Target doses are recommended for both the beta blockers and the ACE inhibitors

• The addition of these agents in indicated patients has been shown to decrease the rates morbidity and mortality

• The purpose of this interim analysis is to determine guideline adherence in regards to ACE inhibitor and beta-blocker therapy

Primary Objective• To determine the percentage of patients being

treated with ACE inhibitors and beta-blockers

Secondary Objectives • To determine the percentage of patients at target

doses of these agents

• To evaluate any barriers that have prevented optimization

• It is expected that there will be some divergence from the recommended pharmacological therapy

• It is presumed that barriers preventing the optimization of therapy may be identified

• Hyperkalemia• Symptomatic bradycardia• Deterioration of renal function• Angioedema• Patient adherence• Reliance on cardiology follow up

In this preliminary review, both beta blockers and ACE inhibitors/ARBs have low rates of optimization

Beta blockers are less frequently optimized than ACE inhibitors

In the majority of cases there is not an obvious, documented barrier to initiating or optimizing therapy with either class

Background

Conclusions

Three patients (9%) had obvious barriers to treatment with a beta blocker− Reported dizziness/orthostatic hypotension impeding optimization (2 patients)

− HF exacerbation requiring discontinuation

Three patients (3%) had a contraindication to treatment with an ACE inhibitor due to deteriorating renal function and/or hyperkalemia

Optimization of therapy was not achieved in one patient due to documented poor adherence.

Seventy-five patients (77%) have been referred to a cardiology clinic

Eighty-one patients (83%) were on diuretic therapy with loop diuretics

Twelve patients (12%) were being treated with aldosterone antagonists− Three (25%) of these patients were optimized on ACE inhibitor/Beta blocker therapy

Ten patients were being treated with hydralazine/isosorbide dinitrate therapy− None of these patients were optimized on

ACE inhibitor/beta blocker therapy

Authors of this presentation have the following to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation: Brad Wright is currently receiving funding from Novartis Pharmaceuticals; all other authors have nothing to disclose.

Disclosure

Objectives

• Medical charts will be reviewed retrospectively to evaluate the pharmacological therapy of patients with heart failure

• The sample was selected from outpatient heart failure patients who were followed at various University-affiliated outpatient primary care clinics between July 1, 2009 and July 31, 2010

• Inclusion Criteria: − Ejection fraction of less than 40 − ICD-9 code for systolic heart failure

• Exclusion Criteria: − Diastolic heart failure− Patients 19 years of age or younger− Patients who are pregnant − Patients who are prisoners

• Adherence to the 2009 ACC/AHA updated treatment guidelines will be evaluated by analyzing:

− Recorded medications− Dose prescribed− Contraindications to therapy

Expected Outcomes

Preliminary ResultsRecommended Target Doses

Methods

Figure 2Preliminary Results

PreliminaryResults

After reviewing the list generated using ICD-9 codes for heart failure for 2 of 3 clinics*, ninety-eight patients were included in this preliminary analysis

Seventy-two patients (74 %) were not on optimized beta blocker therapy

Forty-nine patients (50%) were not on optimized ACE inhibitor therapy

Only 9 patients (9%) were optimized in both drug classes

Bisoprolol 10mg daily

Carvedilol 25mg BID

Carvedilol ER 80mg daily

Metoprolol succinate

200mg daily

Beta Blockers

ACE InhibitorsCaptopril 50-100mg TID

Enalapril 10-20mg BID

Fosinopril 20-40mg daily

Lisinopril 20-40mg daily

Quinapril 10-20mg BID

Ramipril 5-10mg daily

Trandolapril 4mg daily

11%

39%

50%

Patients on ACE Inhibitor Therapy

No Therapy

Non-Optimized Therapy

Optimized Therapy

*Patients from two of three clinics involved with this research

Figure 1Preliminary Results

9%

74%

17%

Patients on Beta Blocker Therapy

No Therapy

Non-Optimized Therapy

Optimized Therapy