In the JournalsPerspective

Medications that worsen HF often initiated, continued after hospitalization

Parag Goyal

Medications known to potentially worsen HF were often started or continued after a hospitalization for HF, according to a study published in JACC: Heart Failure.

“As a heart failure doctor, many of my patients take over 10 medications,” Parag Goyal, MD, MSc, FACC, assistant professor of medicine in the division of cardiology at Weill Cornell Medicine in New York and director of the heart failure with preserved ejection fraction program at Weill Cornell Medicine/NewYork-Presbyterian Hospital, told Cardiology Today. “This high medication burden has been described as ‘polypharmacy’ and is associated with a variety of adverse outcomes. Prior work in this area coupled with findings from our study highlight the need for improved processes of medication review and medication optimization to ensure the safety and well-being of our patients with heart failure.”

Researchers analyzed data from 723 unique HF hospitalizations from 558 patients (median age, 76 years; 44% women; 34% black) aged 65 years and older from the REGARDS study. Hospitalizations included in this study occurred between 2003 and 2014. Admission and discharge medications were also assessed, with a focus on those that may exacerbate HF as per the 2016 American Heart Association scientific statement on medications that may induce or precipitate HF.

Between hospital admission and hospital discharge, 17% of patients had a decrease in the number of medications that would exacerbate HF, 19% were on the same number of medications and 12% had an increase in the number of medications.

The strongest independent determinants of harmful prescribing practice based on a multivariable logistic regression analysis were small hospital size (OR = 1.93; 95% CI, 1.18-3.16) and diabetes (OR = 1.8; 95% CI, 1.18-2.75).

“We ... found that most HF-exacerbating medications were continued following a hospitalization for HF, and that an increase in the number of these potentially harmful medications prescribed at hospital discharge occurred in one out of five hospitalizations,” Goyal and colleagues wrote. “This observation is highly concerning given that this occurred among hospitalizations for HF — a scenario in which an investigation into the cause of HF is paramount to preventing further hospitalizations. This suggests that current medication reconciliation efforts may be suboptimal, supporting prior observations across a broad range of conditions.”

“Many of the medications that can cause harm to heart failure are actually first-line treatments for other conditions,” Goyal said in an interview. “For example, ibuprofen treats pain (which is common in older adults) but can worsen heart failure. Albuterol treats chronic obstructive pulmonary disease (a common condition among older adults with heart failure) but can also worsen heart failure. We need more research to better understand the negative effects of these agents and how best to deal with these scenarios of ‘therapeutic competition.’” – by Darlene Dobkowski

For more information:

Parag Goyal, MD, MSc, FACC, can be reached at Weill Cornell Medicine, 525 E. 68th St., New York, NY 10021; email: pag9051@med.cornell.edu; Twitter: @paraggoyalmd.

Disclosures: Goyal reports he receives research support from Amgen. Please see the study for all other authors’ relevant financial disclosures.

Parag Goyal

Medications known to potentially worsen HF were often started or continued after a hospitalization for HF, according to a study published in JACC: Heart Failure.

“As a heart failure doctor, many of my patients take over 10 medications,” Parag Goyal, MD, MSc, FACC, assistant professor of medicine in the division of cardiology at Weill Cornell Medicine in New York and director of the heart failure with preserved ejection fraction program at Weill Cornell Medicine/NewYork-Presbyterian Hospital, told Cardiology Today. “This high medication burden has been described as ‘polypharmacy’ and is associated with a variety of adverse outcomes. Prior work in this area coupled with findings from our study highlight the need for improved processes of medication review and medication optimization to ensure the safety and well-being of our patients with heart failure.”

Researchers analyzed data from 723 unique HF hospitalizations from 558 patients (median age, 76 years; 44% women; 34% black) aged 65 years and older from the REGARDS study. Hospitalizations included in this study occurred between 2003 and 2014. Admission and discharge medications were also assessed, with a focus on those that may exacerbate HF as per the 2016 American Heart Association scientific statement on medications that may induce or precipitate HF.

Between hospital admission and hospital discharge, 17% of patients had a decrease in the number of medications that would exacerbate HF, 19% were on the same number of medications and 12% had an increase in the number of medications.

The strongest independent determinants of harmful prescribing practice based on a multivariable logistic regression analysis were small hospital size (OR = 1.93; 95% CI, 1.18-3.16) and diabetes (OR = 1.8; 95% CI, 1.18-2.75).

“We ... found that most HF-exacerbating medications were continued following a hospitalization for HF, and that an increase in the number of these potentially harmful medications prescribed at hospital discharge occurred in one out of five hospitalizations,” Goyal and colleagues wrote. “This observation is highly concerning given that this occurred among hospitalizations for HF — a scenario in which an investigation into the cause of HF is paramount to preventing further hospitalizations. This suggests that current medication reconciliation efforts may be suboptimal, supporting prior observations across a broad range of conditions.”

“Many of the medications that can cause harm to heart failure are actually first-line treatments for other conditions,” Goyal said in an interview. “For example, ibuprofen treats pain (which is common in older adults) but can worsen heart failure. Albuterol treats chronic obstructive pulmonary disease (a common condition among older adults with heart failure) but can also worsen heart failure. We need more research to better understand the negative effects of these agents and how best to deal with these scenarios of ‘therapeutic competition.’” – by Darlene Dobkowski

For more information:

Parag Goyal, MD, MSc, FACC, can be reached at Weill Cornell Medicine, 525 E. 68th St., New York, NY 10021; email: pag9051@med.cornell.edu; Twitter: @paraggoyalmd.

Disclosures: Goyal reports he receives research support from Amgen. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    James L. Januzzi

    James L. Januzzi

    These findings once again affirm the need for continuous scrutiny of our patients’ medication lists in order to identify and rectify potential interactions and/or harmful medications.These findings also have immediate implications, as clinicians should be vigilant when verifying medication lists at every visit.It is disappointing that in the era of electronic health records, we cannot expect such medications to be automatically detected. Artificial intelligence should easily be able to identify patients with HF and the presence of potentially risky medications in their program.

    • James L. Januzzi , MD
    • Cardiology Division and Director, Dennis and Marilyn Barry Fellowship in Cardiovascular Research
      Massachusetts General Hospital
      Hutter Family Professor of Medicine
      Harvard Medical School

    Disclosures: Januzzi reports no relevant financial disclosures.