Older patients with heart failure (HF) frequently start or continue medications that exacerbate HF after hospitalization; therefore, safe prescribing practices for this population must be improved, according to study results published in the Journal of the American College of Cardiology: Heart Failure.

The use of pharmacologic agents to reduce HF-related hospitalizations has become a major focus in the United States; however, there has been little attention placed on eliminating agents that may exacerbate HF. In 2016, the American Heart Association released a list of medications that may potentially exacerbate HF, but the prevalence of these medications among older adults hospitalized for HF is currently unknown. The objective of this study was to evaluate patterns of HF-exacerbating medication use among older adults after HF-related hospitalization and examine factors that lead to the use of these medications.

In this study, researchers examined 558 Medicare beneficiaries aged 65 years and older from the Reasons for Geographic and Racial Difference in Stroke cohort study who were hospitalized for HF between 2003 and 2014. Researchers examined whether the patients were using major HF-exacerbating medications at hospital admission and discharge and whether the medications were changed between admission and discharge.

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Major HF-exacerbating medications were defined as agents with life-threatening effects that could lead to hospitalization or an emergency room visit. Multivariable logistic regression analysis was performed to identify whether patients continued HF-exacerbating medications or used a higher number of these medications after HF-related hospitalization.

Of the patients evaluated, the prevalence of HF-exacerbating medications was 41% at hospital admission and 36% at discharge. The most common HF-exacerbating medications used at admission were albuterol, metformin, nonsteroidal anti-inflammatory drugs (NSAIDs), and diltiazem — all of which were the same most common HF-exacerbating medications used at discharge minus NSAIDs. Albuterol had the greatest increase in prevalence between admission and discharge (16%-22%) whereas NSAIDs had the greatest decrease in prevalence (9%-3%).

Furthermore, 17% of patients experienced a decrease in the number of HF-exacerbating medications used between admission and discharge whereas 19% remained on the same number, and 12% experienced an increase in the number of harmful medications used. Results from multivariable logistic regression analysis revealed that the factors most strongly associated with potentially harmful prescribing practice were diabetes (odds ratio 1.80; 95% CI, 1.18-2.75) and small hospital size (odds ratio 1.93; 95% CI, 1.18-3.16).

This study had several limitations. First, researchers could not establish a causal relationship between variables because this was an observational cohort and several hospitalizations did not have medication data at admission or discharge, which could have affected patterns observed in this study. Second, albuterol and NSAIDs were found to be frequently prescribed on an as-needed basis, and therefore the prevalence of these medications may have been underestimated in this study. Third, the scientific statement provided by the American Heart Association only includes a list of potential HF-exacerbating medications, not drug-drug interactions or drug-person interactions that may contribute to HF-related exacerbations, which may have led to an underestimation of the prevalence of harmful medication patterns. Lastly, data for New York Heart Association were not consistently collected; therefore, researchers could not account for this data in the analysis.

The study researchers concluded that the use of HF-exacerbating medications is prevalent among older adults with HF during hospitalization and after discharge — especially among persons with diabetes and persons admitted to small hospitals — and that these findings strongly highlight the need to improve safe prescribing practices for this population.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Goyal P, Kneifati-Hayek J, Archambault A, et al. Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization [published online November 4, 2019]. JACC Heart Fail. doi:10.1016/j.jchf.2019.08.007