International Journal of Cardiology 176 (2014) 1334–1335
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Rates of aldosterone antagonist use after myocardial infarction remain poor over time among guideline eligible patients Houman Khalili, Anthony Edwards, Jacqueline Jones, James A. de Lemos, Sandeep R. Das ⁎ Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, United States
a r t i c l e
i n f o
Article history: Received 10 June 2014 Accepted 27 July 2014 Available online 4 August 2014 Keywords: Aldosterone antagonist ACS Quality improvement Guideline adherence Guidelines Myocardial infarction
The use of aldosterone antagonists (AldAs) after acute myocardial infarction (MI) in patients with left ventricular ejection fraction (LVEF) ≤ 40% and either diabetes mellitus (DM) or symptomatic heart failure (HF) has an established survival benefit [1], and receives a Class I, level of evidence A indication in the current American College of Cardiology/American Heart association (ACC/AHA) guidelines [2,3]. Despite a proven mortality benefit and class I indication, AldA prescription at discharge among guideline-eligible patients without contraindications is remarkably low, ranging from 9 to 15% in contemporary registry studies [4,5], a rate sharply lower than prescription rates for other guideline-indicated post-MI medications. However, these recently published reports were limited to the index hospitalization and thus may not capture initiation of AldA early after hospital discharge, which would also be in accordance with landmark studies and current guidelines. To address this limitation of the current literature, we assessed the AldA prescription pattern over time post-discharge at a large academic tertiary care center for MI patients who met guideline indications for AldA therapy.
Abbreviations: AldA, aldosterone antagonist; MI, myocardial infarction; LVEF, left ventricular ejection fraction; DM, diabetes mellitus; HF, heart failure; STEMI, ST-elevation myocardial infarction; NSTEMI, non-ST-elevation myocardial infarction. ⁎ Corresponding author at: UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-8830, United States. E-mail address: [email protected] (S.R. Das).
http://dx.doi.org/10.1016/j.ijcard.2014.07.146 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
After obtaining approval from the UT Southwestern IRB, we retrospectively reviewed medical records of all patients treated at Parkland Memorial Hospital (Dallas, TX) with primary discharge diagnosis of MI from 2008 to 2013 who had ≥ 1 year of post-MI follow-up available. In order to exclude patients with non-ACS presentations, the diagnosis of type 1 MI was adjudicated by a team of cardiologists blinded to post-discharge care. Inclusion criteria were LVEF ≤ 40% and either symptomatic heart failure or diabetes mellitus; exclusion criteria were serum potassium N 5 mmol/L and either serum creatinine N2 mg/dL for men or N2.5 mg/dL for women [2,6]. Patients were also excluded if a contraindication to both angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin receptor blocker (ARB) or to AldA therapy was documented. Of 371 patients with type 1 MI, 58 met inclusion criteria. Three patients were excluded due to hyperkalemia or elevated creatinine, leaving 55 as the final analysis cohort. AldA prescription over time was determined by manual review of the electronic medical record for each patient. Among eligible patients, 43.6% (n = 24) had STEMI as their index MI, 47.3% (n = 26) had diabetes mellitus, and mean LVEF was 33% (Table 1). Of the 55 eligible patients, 7% (n = 4) were prescribed AldA at discharge, three of whom were on AldA prior to admission. By 14day follow-up, two additional patients (cumulative total 11%; n = 6) had been prescribed AldA. Over a median follow-up period of 1.5 years, a total of 13 eligible patients (24%) were prescribed AldA (Fig. 1). To our knowledge, this is the first study examining AldA prescription pattern in guideline eligible MI patients after hospital discharge. By the end of the short-term post discharge follow-up period (3–14 days) [7], only 1 in 9 patients had been prescribed AldA. There are several possible explanations for the failure to translate clinical trial data and guideline recommendations regarding AldA into practice. AldAs are a generic class of medications, with no pharmaceutical detailing or marketing, which likely contributes to lower awareness of this therapy among clinicians. Moreover, AldA is considered a “layered therapy” in the AHA/ACC performance measures for management of hospitalized post-MI patients [6], and not a discharge performance metric. For some patients, the need to initiate multiple guidelinerecommended post-MI therapies may contribute to delay in initiation of AldA. In addition, AldA is recommended for patients on goal doses of ACE-I or ARB [3,6] potentially further delaying the initiation of AldA. However, few patients were initiated on AldA even over a median follow-up of 1.5 years, suggesting that the reluctance to prescribe AldA is more than a short-term deferral. Other potential barriers to
H. Khalili et al. / International Journal of Cardiology 176 (2014) 1334–1335 Table 1 Baseline characteristics of patients. Characteristics Age (years) Female Race or ethnic group White Black Asian Hispanic Other STEMI Left ventricular ejection fraction Cardiovascular risk factors Diabetes mellitus Hypertension Hyperlipidemia Recent tobacco use Cardiovascular disease history Prior MI Prior heart failure Prior CVA On AldA prior to current MI
N = 55 68 (42–81) 13 (23.6%) 37 (67.3%) 12 (21.8%) 5 (9.1%) 22 (40.0%) 1 (1.8%) 24 (43.6%) 33% (17%–40%) 26 (47.3%) 42 (76.4%) 34 (61.8%) 22 (40.0%) 23 (41.8%) 13 (23.6%) 11 (20.0%) 3 (5.5%)
STEMI = ST elevation myocardial infarction; MI = myocardial infarction; CVA = cerebrovascular accident; AldA = aldosterone antagonist.
AldA prescription are clinicians' concerns for hyperkalemia or other adverse effects. Several potential limitations of our study deserve mention. Although AldA prescription at discharge in this study was consistent with previous national data, the long-term prescription patterns observed here may not reflect AldA use elsewhere. A larger multi-center observational study could help further elucidate this issue. Despite excluding patients with elevated serum creatinine or potassium, and other clearly documented contraindications, patients with potentially undocumented contraindications may have been included in our final analysis.
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Our single center experience shows poor adoption of guideline recommended AldA in post-MI patients both at discharge and long-term follow-up. Given a clear mortality benefit with AldA in this patient population, quality-improvement initiatives are needed to optimize AldA prescription patterns. Conflict of interest None. References [1] Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003;348:1309–21. [2] O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:e362–425. [3] Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2007;116:e148–304. [4] Rassi AN, Cavender MA, Fonarow GC, et al. Temporal trends and predictors in the use of aldosterone antagonists post-acute myocardial infarction. J Am Coll Cardiol 2013; 61:35–40. [5] Rao KK, Enriquez JR, de Lemos JA, et al. Use of aldosterone antagonists at discharge after myocardial infarction: results from the national cardiovascular data registry acute coronary treatment and intervention outcomes network (ACTION) registry-get with the guidelines (GWTG). Am Heart J 2013;166: 709–15. [6] Krumholz HM, Anderson JL, Bachelder BL, et al. ACC/AHA 2008 performance measures for adults with st-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circulation 2008;118: 2596–648. [7] Adamopoulos C, Ahmed A, Fay R, et al. Timing of eplerenone initiation and outcomes in patients with heart failure after acute myocardial infarction complicated by left ventricular systolic dysfunction: insights from the EPHESUS trial. Eur J Heart Fail 2009;11:1099–105.
Fig. 1. Proportion of patients prescribed aldosterone antagonist on hospital discharge and long-term follow-up.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Rates of aldosterone antagonist use after myocardial infarction remain poor over time among guideline eligible patients Houman Khalili, Anthony Edwards, Jacqueline Jones, James A. de Lemos, Sandeep R. Das ⁎ Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, United States
a r t i c l e
i n f o
Article history: Received 10 June 2014 Accepted 27 July 2014 Available online 4 August 2014 Keywords: Aldosterone antagonist ACS Quality improvement Guideline adherence Guidelines Myocardial infarction
The use of aldosterone antagonists (AldAs) after acute myocardial infarction (MI) in patients with left ventricular ejection fraction (LVEF) ≤ 40% and either diabetes mellitus (DM) or symptomatic heart failure (HF) has an established survival benefit [1], and receives a Class I, level of evidence A indication in the current American College of Cardiology/American Heart association (ACC/AHA) guidelines [2,3]. Despite a proven mortality benefit and class I indication, AldA prescription at discharge among guideline-eligible patients without contraindications is remarkably low, ranging from 9 to 15% in contemporary registry studies [4,5], a rate sharply lower than prescription rates for other guideline-indicated post-MI medications. However, these recently published reports were limited to the index hospitalization and thus may not capture initiation of AldA early after hospital discharge, which would also be in accordance with landmark studies and current guidelines. To address this limitation of the current literature, we assessed the AldA prescription pattern over time post-discharge at a large academic tertiary care center for MI patients who met guideline indications for AldA therapy.
Abbreviations: AldA, aldosterone antagonist; MI, myocardial infarction; LVEF, left ventricular ejection fraction; DM, diabetes mellitus; HF, heart failure; STEMI, ST-elevation myocardial infarction; NSTEMI, non-ST-elevation myocardial infarction. ⁎ Corresponding author at: UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-8830, United States. E-mail address: [email protected] (S.R. Das).
http://dx.doi.org/10.1016/j.ijcard.2014.07.146 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
After obtaining approval from the UT Southwestern IRB, we retrospectively reviewed medical records of all patients treated at Parkland Memorial Hospital (Dallas, TX) with primary discharge diagnosis of MI from 2008 to 2013 who had ≥ 1 year of post-MI follow-up available. In order to exclude patients with non-ACS presentations, the diagnosis of type 1 MI was adjudicated by a team of cardiologists blinded to post-discharge care. Inclusion criteria were LVEF ≤ 40% and either symptomatic heart failure or diabetes mellitus; exclusion criteria were serum potassium N 5 mmol/L and either serum creatinine N2 mg/dL for men or N2.5 mg/dL for women [2,6]. Patients were also excluded if a contraindication to both angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin receptor blocker (ARB) or to AldA therapy was documented. Of 371 patients with type 1 MI, 58 met inclusion criteria. Three patients were excluded due to hyperkalemia or elevated creatinine, leaving 55 as the final analysis cohort. AldA prescription over time was determined by manual review of the electronic medical record for each patient. Among eligible patients, 43.6% (n = 24) had STEMI as their index MI, 47.3% (n = 26) had diabetes mellitus, and mean LVEF was 33% (Table 1). Of the 55 eligible patients, 7% (n = 4) were prescribed AldA at discharge, three of whom were on AldA prior to admission. By 14day follow-up, two additional patients (cumulative total 11%; n = 6) had been prescribed AldA. Over a median follow-up period of 1.5 years, a total of 13 eligible patients (24%) were prescribed AldA (Fig. 1). To our knowledge, this is the first study examining AldA prescription pattern in guideline eligible MI patients after hospital discharge. By the end of the short-term post discharge follow-up period (3–14 days) [7], only 1 in 9 patients had been prescribed AldA. There are several possible explanations for the failure to translate clinical trial data and guideline recommendations regarding AldA into practice. AldAs are a generic class of medications, with no pharmaceutical detailing or marketing, which likely contributes to lower awareness of this therapy among clinicians. Moreover, AldA is considered a “layered therapy” in the AHA/ACC performance measures for management of hospitalized post-MI patients [6], and not a discharge performance metric. For some patients, the need to initiate multiple guidelinerecommended post-MI therapies may contribute to delay in initiation of AldA. In addition, AldA is recommended for patients on goal doses of ACE-I or ARB [3,6] potentially further delaying the initiation of AldA. However, few patients were initiated on AldA even over a median follow-up of 1.5 years, suggesting that the reluctance to prescribe AldA is more than a short-term deferral. Other potential barriers to
H. Khalili et al. / International Journal of Cardiology 176 (2014) 1334–1335 Table 1 Baseline characteristics of patients. Characteristics Age (years) Female Race or ethnic group White Black Asian Hispanic Other STEMI Left ventricular ejection fraction Cardiovascular risk factors Diabetes mellitus Hypertension Hyperlipidemia Recent tobacco use Cardiovascular disease history Prior MI Prior heart failure Prior CVA On AldA prior to current MI
N = 55 68 (42–81) 13 (23.6%) 37 (67.3%) 12 (21.8%) 5 (9.1%) 22 (40.0%) 1 (1.8%) 24 (43.6%) 33% (17%–40%) 26 (47.3%) 42 (76.4%) 34 (61.8%) 22 (40.0%) 23 (41.8%) 13 (23.6%) 11 (20.0%) 3 (5.5%)
STEMI = ST elevation myocardial infarction; MI = myocardial infarction; CVA = cerebrovascular accident; AldA = aldosterone antagonist.
AldA prescription are clinicians' concerns for hyperkalemia or other adverse effects. Several potential limitations of our study deserve mention. Although AldA prescription at discharge in this study was consistent with previous national data, the long-term prescription patterns observed here may not reflect AldA use elsewhere. A larger multi-center observational study could help further elucidate this issue. Despite excluding patients with elevated serum creatinine or potassium, and other clearly documented contraindications, patients with potentially undocumented contraindications may have been included in our final analysis.
1335
Our single center experience shows poor adoption of guideline recommended AldA in post-MI patients both at discharge and long-term follow-up. Given a clear mortality benefit with AldA in this patient population, quality-improvement initiatives are needed to optimize AldA prescription patterns. Conflict of interest None. References [1] Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003;348:1309–21. [2] O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:e362–425. [3] Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2007;116:e148–304. [4] Rassi AN, Cavender MA, Fonarow GC, et al. Temporal trends and predictors in the use of aldosterone antagonists post-acute myocardial infarction. J Am Coll Cardiol 2013; 61:35–40. [5] Rao KK, Enriquez JR, de Lemos JA, et al. Use of aldosterone antagonists at discharge after myocardial infarction: results from the national cardiovascular data registry acute coronary treatment and intervention outcomes network (ACTION) registry-get with the guidelines (GWTG). Am Heart J 2013;166: 709–15. [6] Krumholz HM, Anderson JL, Bachelder BL, et al. ACC/AHA 2008 performance measures for adults with st-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circulation 2008;118: 2596–648. [7] Adamopoulos C, Ahmed A, Fay R, et al. Timing of eplerenone initiation and outcomes in patients with heart failure after acute myocardial infarction complicated by left ventricular systolic dysfunction: insights from the EPHESUS trial. Eur J Heart Fail 2009;11:1099–105.
Fig. 1. Proportion of patients prescribed aldosterone antagonist on hospital discharge and long-term follow-up.
