Systolic Heart Failure Therapy in Dialysis Patients
What are the temporal trends in the adherence to heart failure (HF)–related process of care measures and clinical outcomes among hospitalized systolic HF patients on long-term dialysis for end-stage renal disease (ESRD)?
The study cohort was comprised of Get With The Guidelines-HF study participants who were admitted for acute HF with reduced ejection fraction (HFrEF) between January 2005 and June 2014. They were stratified into three groups on the basis of their admission renal function: normal renal function, renal insufficiency without dialysis, and dialysis. In these three functional groups, the study authors evaluated temporal change in proportional adherence to the HF-related process of care measures and incidence of clinical outcomes (1-year mortality, HF hospitalization, and all-cause hospitalization). They obtained the data on mortality from Centers for Medicaid and Medicare Services (CMS) enrollment files, and hospitalization data were obtained from Part A inpatient claims files. They used the Cochran-Armitage trend test to compare temporal trends in adherence to the different HF process of care measures across the three groups. Multivariable Cox proportional hazards regression was performed to determine if there was a significant change in the risk of 1-year mortality, 1-year all-cause hospitalization, and 1-year HF-specific hospitalization over time.
The study included 111,846 unique hospitalizations with HFrEF from 390 participating centers, of whom 78% (n = 87,411) had normal renal function, 19% (n = 21,194) had renal insufficiency that did not require dialysis, and 3% (n = 3,241) were on dialysis at admission. There was a significant temporal increase in adherence to evidence-based medical therapies (angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker: p trend < 0.0001, beta-blockers: p trend = 0.0089; post-discharge follow-up referral: p trend < 0.0001) and defect-free composite care (p trend < 0.0001) among dialysis patients. An improvement in adherence to these measures was also observed among patients with normal renal function and patients with renal insufficiency without a need for dialysis. There was no significant change in cumulative incidence of clinical outcomes over time among the HF patients on dialysis.
The authors concluded that in a contemporary cohort of HFrEF patients with ESRD, adherence to the HF process of care measures has improved significantly over the past 10 years. Unlike patients with normal renal function, however, there was no significant change in 1-year clinical outcomes over time among HF patients on dialysis.
It is heartening to note that utilization of guideline-directed therapy in HF has improved. However, improving outcomes in multiorgan failure is a challenge. More prospective studies are needed to determine whether optimal therapy in cardiorenal failure is the same as in systolic HF without ESRD.
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