Non-adherence leads to poor outcomes in CHF patients

February 1, 2013

ARBs and ACE inhibitors prolong life and help patients maintain daily living activities.

Chronic heart failure (CHF)-affecting about 5.8 million people in the United States-is a condition in which the heart can't pump enough blood to meet the body's needs. The lungs may become congested with fluid, and fluid may build up in the feet, legs, and abdomen. However, some patients do not experience congestion.

Angiotensin converting enzyme (ACE) inhibitors act by preventing the formation of angiotensin II, a chemical that causes the muscles surrounding blood vessels to contract, thereby narrowing blood vessels. ACE inhibitors are used to open blood vessels and reduce the amount of heart-damaging hormones the body produces.

“Most experts recommend prescribing an ACE inhibitor for all patients with symptomatic heart failure and for asymptomatic patients with a history of heart attack, or with a decreased ability to pump blood,” says Mark Abramowicz, MD, editor-in-chief of The Medical Letter on Drugs and Therapeutics, a non-profit newsletter that critically appraises drugs.

Angiotensin receptor blockers (ARBs) are similar to ACE inhibitors, but they act by blocking the binding of angiotensin II to muscles on blood vessels.

“ARBs should be used in patients with heart failure and a decreased ability to pump blood who cannot tolerate the cough often induced by ACE inhibitors,” says Dr. Abramowicz.

The medications make patients with heart failure feel better and help them be able to do more activities of daily living, says Gregg C. Fonarow, MD, director of the Ahmanson-UCLA Cardiomyopathy Center at the David Geffen School of Medicine at UCLA.

“They modify the disease process; they are truly life-prolonging therapies,” he says.

He emphasizes the importanceof maintaining and adjusting appropriate medications for heart failure patients.

“Adherence to medications is absolutely critical, but with the complexity of the medical regimen, non-adherence is a great problem in heart failure and contributes to disparities in outcomes,” he says. “We see in a variety of settings that medications may be discontinued inadvertently or even deliberately by physicians or nurses who do not recognize the full benefits of the therapy and the appropriate indications. Appropriate medication needs to be an intense focus in every setting where heart failure patients are cared for.”

 He notes that the two classes of medications are related and work in a similar way. One or the other can be used in heart failure patients, but the two together do not add any additional benefit.

Beta-blockers have a direct effect on the heart muscle to lessen the heart’s workload. Most guidelines recommend use of a beta-blocker in addition to an ACE inhibitor for patients who have symptomatic systolic heart failure and for asymptomatic patients who have a deceased ability to pump blood.

“Use of bisoprolol, carvedilol or sustained-release metoprolol succinate consistently leads to a 30% to 40% reduction in mortality and hospitalization in adults with New York Heart Association (NYHA) class II–IV heart failure,” says Dr. Abramowicz. “Beta-blockers should be started at a low dose, and the dosage increased gradually, usually at two-week intervals.”

Aldosterone antagonists were originally developed for high blood pressure patients, but they were also found to be beneficial in heart failure patients.

“Aldosterone antagonists have an added benefit on top of ACE inhibitors and beta-blockers,” says Dr. Fonarow. “These three neurohormones when used together can substantially lower the mortality risk in heart failure patients, and help keep them out of the hospital. These medications do require proper initiation, monitoring of dosage and checking of laboratory results.”

In October 2012, a significant number of hospitals began receiving reduced payments from Medicare, due to high readmission rates for chronic heart failure and two other conditions.

Currently the reductions range up to a one percent decrease on all Medicare reimbursements. Hospitals that aren't able to bring reduce readmission rates will face a maximum 2% penalty for fiscal 2014 and 3% for 2015.

“Studies have shown that heart failure has the highest readmission rate within 30 days compared to any other medical or surgical condition, and there has been a growing recognition that at least some portion of these readmissions may in fact be preventable,” Dr. Fonarow says.

About 4,000 hospitals care for patients with acute problems such as heart failure; CMS identified more than 2,000 hospitals with “readmission rates higher than desirable” that face penalties.

“Federal officials were not just going after a small proportion of hospitals that were outliers. People were surprised by the number of affected hospitals, and there has been a substantial controversy around this,” Dr. Fonarow says.

Currently, about one in four Medicare beneficiaries with have heart failure are re-hospitalized within 30 days, although some hospitals have much lower readmission rates.

“We have to recognize these patients often have multiple other co-morbid conditions, are old and often having limited social support, or may be on complex medical regimens to treat their heart failure and other conditions,” Dr. Fonarow says.

He emphasizes the importance, and the challenge, of maintaining and adjusting appropriate medications for heart failure patients.

“Adherence to medications is absolutely critical, but with the complexity of the medical regimen, non-adherence is a great problem in heart failure and contributes to disparities in outcomes,” he says. “We see in a variety of settings that medications may be discontinued inadvertently or even deliberately by physicians or nurses who do not recognize the full benefits of the therapy and the appropriate indications. Appropriate medication needs to be an intense focus in every setting where heart failure patients are cared for.”