- Email: [email protected]
Outpatient utilization of angiotensin-converting enzyme inhibitors (ACEI) among heart failure (HF) patients after hospital discharge
Heart Failure/Transplant
Study Question: Nonselective, nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with an increased risk of congestive heart failure (CHF), but little is known about the cardiovascular effects of a newer group of NSAIDS called selective cyclo-oxygenase (COX)-2 inhibitors. The investigators sought to compare rates of admission for CHF in elderly patients who were given either newly dispensed COX-2 inhibitors or nonselective NSAIDs. Methods: This was a population-based retrospective cohort study. Investigators identified NSAID-naive individuals aged 66 years or older who were started on rofecoxib (n⫽14,583), celecoxib (n⫽18,908), and nonselective NSAIDs (n⫽5391), and randomly selected non-NSAID users as controls (n⫽100,000). Results: Relative to non-NSAID users, patients on rofecoxib and nonselective NSAIDS had an increased risk of admission for CHF (adjusted rate ratio 1.8, 95% CI 1.5–2.2, and 1.4, 1.0 –1.9, respectively), but this was not observed for celecoxib (1.0, 0.8 –1.3). Compared with celecoxib users, admission for CHF was significantly more likely in users of nonselective NSAIDs (1.4, 1.0 –1.9) and rofecoxib (1.8, 1.4 –2.4). Risk of admission for rofecoxib users was higher than that for nonselective NSAID users (1.5, 1.1–2.1). In patients with no admission for CHF in the past 3 years, only rofecoxib users were at increased risk of subsequent admission relative to controls (1.8, 1.4 –2.3). Conclusions: Investigators concluded that these findings suggest a higher risk of admission for CHF in users of rofecoxib and nonselective NSAIDs relative to non-NSAID controls and those given celecoxib. Perspective: The study suggests significant differences between nonselective NSAIDs and individual COX-2 inhibitors with respect to risk of admission for CHF. The findings raise additional concerns about the detrimental cardiovascular effects of some of the selective COX-2 inhibitors. In view of the widespread use of these drugs, this study along with prior observations argues for large-scale randomized clinical trials to examine the cardiovascular safety of coxibs. DM
Abstracts Outpatient Utilization of Angiotensin-Converting Enzyme Inhibitors (ACEI) Among Heart Failure (HF) Patients After Hospital Discharge Butler J, Daugherty PA, Jain M, Ray W, Griffin MR. J Am Coll Cardiol 2004;43:2036 – 43. Study Question: Following HF hospitalization, how many patients continue to be on ACEI in the first year? Methods: The study examined 219 patients with depressed ejection fraction (EF) and a total of 960 patients recently hospitalized for HF. Determinants for filling an ACEI prescription in the 30 days after discharge and the proportion of patients who filled such prescriptions subsequently up to 1 year following discharge were studied. Results: Only 67% of patients with reduced EF and 55% of the total study group were discharged with ACEIs. Furthermore, overall 81.2% and 77.1% (reduced EF and total study group) of survivors discharged with ACEIs had filled a prescription within 30 days following discharge; only 66.3%/63.3%, respectively, were current users at the end of 1 year. Not surprisingly, for patients with no discharge order for ACEIs, only 12.7% and 12.0% (reduced EF and total study group) had filled such a prescription by 30 days, and 12.5% and 18.8%, respectively, were current users at 365 days’ postdischarge. HF patients with discharge instructions for ACEIs were more likely to fill a prescription within a month following discharge (hazard ratio 10.93; 95% confidence interval 5.28, 22.61 for patients with reduced EF). Conclusions: The authors concluded that HF patients prescribed an ACEI on discharge showed a significant decline in use on follow-up. Also, patients who were not discharged on ACEIs were unlikely to be started as outpatients. Perspective: Although most clinicians are aware that ACEIs are underutilized in HF, I was dismayed by the findings of this study, particularly because patients in this cohort were eligible for pharmacy benefits. Both patients and healthcare providers must be given incentive to increase the utilization of life-saving ACEI therapy. Every healthcare provider must strive to replicate efforts of the ACC-GAP initiative to increase utilization of ACEIs and other lifesaving therapy such as -blockers in HF. RB
Impaired Baroreceptor Control of Renal Sympathetic Activity in Human Chronic Heart Failure Al-Hesayan A, Parker JD. Circulation 2004;109:2862–5. Study Question: How is renal sympathetic activity affected in chronic heart failure (HF)? Methods: Investigators studied 11 patients with HF and 11 with normal left ventricular systolic function. They used renal norepinephrine spillover in response to unloading by steady-state infusion of sodium nitroprusside to determine baroreceptor control of renal sympathetic activity. Results: Investigators found significant reductions in blood pressure in both groups (normal group, ⫺13⫾1% [mean⫾SEM]; heart failure group, ⫺12⫾1%). In the nor-
Cyclo-oxygenase-2 Inhibitors Versus Nonselective, Nonsteroidal Anti-inflammatory Drugs and Congestive Heart Failure Outcomes in Elderly Patients: A Population-Based Cohort Study Mamdani M, Juurlink DN, Lee DS, et al. Lancet 2004;363:1751– 6.
ACC CURRENT JOURNAL REVIEW Aug 2004
30
Study Question: Nonselective, nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with an increased risk of congestive heart failure (CHF), but little is known about the cardiovascular effects of a newer group of NSAIDS called selective cyclo-oxygenase (COX)-2 inhibitors. The investigators sought to compare rates of admission for CHF in elderly patients who were given either newly dispensed COX-2 inhibitors or nonselective NSAIDs. Methods: This was a population-based retrospective cohort study. Investigators identified NSAID-naive individuals aged 66 years or older who were started on rofecoxib (n⫽14,583), celecoxib (n⫽18,908), and nonselective NSAIDs (n⫽5391), and randomly selected non-NSAID users as controls (n⫽100,000). Results: Relative to non-NSAID users, patients on rofecoxib and nonselective NSAIDS had an increased risk of admission for CHF (adjusted rate ratio 1.8, 95% CI 1.5–2.2, and 1.4, 1.0 –1.9, respectively), but this was not observed for celecoxib (1.0, 0.8 –1.3). Compared with celecoxib users, admission for CHF was significantly more likely in users of nonselective NSAIDs (1.4, 1.0 –1.9) and rofecoxib (1.8, 1.4 –2.4). Risk of admission for rofecoxib users was higher than that for nonselective NSAID users (1.5, 1.1–2.1). In patients with no admission for CHF in the past 3 years, only rofecoxib users were at increased risk of subsequent admission relative to controls (1.8, 1.4 –2.3). Conclusions: Investigators concluded that these findings suggest a higher risk of admission for CHF in users of rofecoxib and nonselective NSAIDs relative to non-NSAID controls and those given celecoxib. Perspective: The study suggests significant differences between nonselective NSAIDs and individual COX-2 inhibitors with respect to risk of admission for CHF. The findings raise additional concerns about the detrimental cardiovascular effects of some of the selective COX-2 inhibitors. In view of the widespread use of these drugs, this study along with prior observations argues for large-scale randomized clinical trials to examine the cardiovascular safety of coxibs. DM
Abstracts Outpatient Utilization of Angiotensin-Converting Enzyme Inhibitors (ACEI) Among Heart Failure (HF) Patients After Hospital Discharge Butler J, Daugherty PA, Jain M, Ray W, Griffin MR. J Am Coll Cardiol 2004;43:2036 – 43. Study Question: Following HF hospitalization, how many patients continue to be on ACEI in the first year? Methods: The study examined 219 patients with depressed ejection fraction (EF) and a total of 960 patients recently hospitalized for HF. Determinants for filling an ACEI prescription in the 30 days after discharge and the proportion of patients who filled such prescriptions subsequently up to 1 year following discharge were studied. Results: Only 67% of patients with reduced EF and 55% of the total study group were discharged with ACEIs. Furthermore, overall 81.2% and 77.1% (reduced EF and total study group) of survivors discharged with ACEIs had filled a prescription within 30 days following discharge; only 66.3%/63.3%, respectively, were current users at the end of 1 year. Not surprisingly, for patients with no discharge order for ACEIs, only 12.7% and 12.0% (reduced EF and total study group) had filled such a prescription by 30 days, and 12.5% and 18.8%, respectively, were current users at 365 days’ postdischarge. HF patients with discharge instructions for ACEIs were more likely to fill a prescription within a month following discharge (hazard ratio 10.93; 95% confidence interval 5.28, 22.61 for patients with reduced EF). Conclusions: The authors concluded that HF patients prescribed an ACEI on discharge showed a significant decline in use on follow-up. Also, patients who were not discharged on ACEIs were unlikely to be started as outpatients. Perspective: Although most clinicians are aware that ACEIs are underutilized in HF, I was dismayed by the findings of this study, particularly because patients in this cohort were eligible for pharmacy benefits. Both patients and healthcare providers must be given incentive to increase the utilization of life-saving ACEI therapy. Every healthcare provider must strive to replicate efforts of the ACC-GAP initiative to increase utilization of ACEIs and other lifesaving therapy such as -blockers in HF. RB
Impaired Baroreceptor Control of Renal Sympathetic Activity in Human Chronic Heart Failure Al-Hesayan A, Parker JD. Circulation 2004;109:2862–5. Study Question: How is renal sympathetic activity affected in chronic heart failure (HF)? Methods: Investigators studied 11 patients with HF and 11 with normal left ventricular systolic function. They used renal norepinephrine spillover in response to unloading by steady-state infusion of sodium nitroprusside to determine baroreceptor control of renal sympathetic activity. Results: Investigators found significant reductions in blood pressure in both groups (normal group, ⫺13⫾1% [mean⫾SEM]; heart failure group, ⫺12⫾1%). In the nor-
Cyclo-oxygenase-2 Inhibitors Versus Nonselective, Nonsteroidal Anti-inflammatory Drugs and Congestive Heart Failure Outcomes in Elderly Patients: A Population-Based Cohort Study Mamdani M, Juurlink DN, Lee DS, et al. Lancet 2004;363:1751– 6.
ACC CURRENT JOURNAL REVIEW Aug 2004
30