Medication Initiation in Patients Hospitalized With Heart Failure

Study Questions:

What is the difference between the actual medication regimen at the time of admission for a hospitalization for heart failure (HF) and the recommended medication regimen at the time of discharge, according to national guidelines and quality measures?


This was a cross-sectional study using the Get With The Guidelines-Heart Failure (GWTG-HF) voluntary quality improvement initiative. The current analysis was restricted to hospital admission between April 2008 and June 2013. The following were medication quality metrics defined by GWTG-HF during the study period: 1) angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) for left ventricular ejection fraction (LVEF) <40%, 2) beta-blocker (BB) for LVEF <40%, 3) aldosterone antagonist (AldA) for LVEF <35%, 4) hydralazine/isosorbide dinitrate (H/ISDN) for LVEF <40% among African-American patients, and 5) anticoagulants for those with atrial fibrillation. Contraindication and intolerances were selected from a drop-down list of approved reasons. The authors calculated the difference between the patient’s medication regimen at the time of admission and what would be recommended by current guidelines and quality measures at the time of discharge, as well as the number of new HF medications actually prescribed at discharge.


The final study sample included 158,922 patients from 271 hospitals. ACE/ARB initiation was indicated in 18.1% of all patients, BB in 20.3%, AldA in 24.1%, H/ISDN in 8.6%, and anticoagulant in 18.0%. Cumulatively, 0.4% of patients were eligible for five new medication groups, 4.1% for four, 9.4% for three, 10.1% for two, and 22.7% for one; 15.0% were not eligible for new medications because of adequate prescribing at admission; and 38.4% were not eligible for any medications recommended by HF quality measures.


The authors concluded that about one in every four patients hospitalized with HF need to start more than one medication to meet HF quality measures.


The authors demonstrate that nearly 50% of patients hospitalized with HF need to start at least one new medication. Although the authors do not have data on post-discharge adherence or outcomes, the authors draw attention to medication initiation in patients with HF. As the authors suggest, ‘Research into the relative benefit of mass initiation of medications prior to discharge versus sequential initiation that extends into the ambulatory setting is needed.’ ‘Mass initiation’ has the potential for greater/sustained long-term adherence.

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