117 Medicines optimisation before discharge in patients admitted to hospital with heart failure

• Published in: Heart (British Cardiac Society) Vol. 108; no. Suppl 1; pp. A87 - A89
• Main Authors: Cuthbert, Joe, Brown, Oliver, Pellicori, Pierpaolo, Dobbs, Karen, Bulemfu, Jeanne, Kazmi, Syed, Sokoreli, Ioanna, Pauws, Steffen, Riistama, Jarno, Cleland, John, Clark, Andrew
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group Ltd and British Cardiovascular Society 06.06.2022; BMJ Publishing Group LTD
• Subjects: Blood pressure; Diuretics; Drug dosages; Enzymes; Heart failure; Heart rate; Medicines optimisation; Sacubitril Valsartan; Sodium Glucose Co-Transporter-2 Inhibitors; United Kingdom > UK
• ISSN: 1355-6037; 1468-201X
• DOI: 10.1136/heartjnl-2022-BCS.117

BackgroundIn the UK, approximately half of patients with heart failure and a reduced ejection fraction (HeFREF) are discharged from hospital on triple therapy (angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), beta-blockers (BB), and mineralocorticoid receptor antagonists (MRA). It is unknown what proportion of patients would be eligible for uptitration of medicines prior to discharge, nor how many might be eligible for initiation of sacubitril-valsartan or sodium-glucose co-transporter-2 inhibitors (SGLT2I).MethodsBetween 2012 and 2017, 1,277 patients admitted with suspected heart failure were enrolled at a single hospital serving a local community around Kingston-Upon-Hull, UK. Eligibility for sacubitril-valsartan or SGLT2I was based on entry criteria for the PIONEER-HF, DAPA-HF and EMPEROR-Reduced trials.Results455 patients had HeFREF with complete data on renal function, heart rate and systolic blood pressure (SBP) on discharge. 83% were taking an ACEI/ARB, 85% a BB and 63% MRA on discharge (figure 1). More than 60% were eligible for sacubitril-valsartan and more than 70% for SGLT2i (figure 2). Among those not already receiving a each drug, 37%, 28%, and 49% were eligible to start ACEI/ARB, BB, or MRA respectively (tables 1 and 2). Low SBP (<105 mmHg) was the most common reason for failure to initiate or up-titrate (table 2).Abstract 117 Table 1 Class Drug N (%)† Low Dose High dose Step 1 Step 2 Step 3 ACEI Enalapril 74 (19) 2.5mg BD 5mg BD 10-20mg BD Ramipril 253 (66) 1.25mg BD 2.5mg BD 5mg BD Perindopril 10 (3) 2.5mg OD 5mg OD 10mg OD Lisinopril 10 (3) 5mg OD 10mg OD 20-35mg OD ARB Candesartan 15 (4) 4-8mg OD 16mg OD 32mg OD Losartan 15 (4) 50mg OD 100mg OD 150mg OD Valsartan 2 (1) 40mg BD 80mg BD 160mg BD Beta-blocker Bisoprolol 116 (30) 2.5mg OD 5mg OD 10mg OD Carvedilol 262 (68) 3.125-6.25 mg BD 12.5mg BD 25-50mg BD Nebivolol 5 (1) 1.25 – 2.50 mg OD 5mg OD 10mg BD Timolol 2 (1) 5mg BD 10mg BD Atenolol 1 (0) 25mg OD 50mg OD MRA Spironolactone 169 (59) 25mg OD 50mg OD Eplerenone 170 (41) 25mg OD 50mg OD † - Percentage of those taking that class of medicationAbstract 117 Table 2Reasons for non-prescription or non-uptitration of medications Reason ACEI or ARB Β-blocker MRA S0 → S1 N=76 S1 → S2 N=175 S2 → S3 N=154 S0 → S1 N=69 S1 → S2 N=211 S2 → S3 N=121 S0 → S1 N=169 S1 → S2 N=282 SBP <90 mmHg – N (%)a 3 (4) 13 (7) 8 (5) 6 (9) 9 (4) 7 (6) 9 (5) 14 (5) SBP <105 mmHg – N (%)b 25 (33) 70 (40) 56 (36) 23 (33) 74 (35) 51 (42) 60 (36) 100 (36) eGFR <30 ml/min/1.73m2 or Cr >221 µmmol/La/b 10 (12) 15 (9) 13 (8) NA NA NA 25 (15) 14 (5) Potassium >5.0 mmol/La/b 7 (9) 18 (10) 9 (6) NA NA NA 14 (8) 18 (6) Heart rate <50 bpma NA NA NA 0 2 (1) 1 (1) NA NA Heart rate <70 in SR or <80 in AF – N (%)b NA NA NA 37 (54) 109 (52) 64 (53) NA NA Severe valvular heart disease 7 (9) 8 (5) 2 (1) 3 (4) 10 (5) 4 (3) 6 (4) 11 (4) Palliative 8 (11) NA NA 7 (10) NA NA 6 (4) NA Documented intolerance or allergy in the medical notes – N (%) 20 (26) 14 (20) 5 (3) Hyperkalaemia - N 1 NA 0 Hypotension - N 1 0 0 Renal dysfunction – N 3 NA 4 Cough – N 1 NA NA Angio-oedema – N 0 NA NA Bradycardia - N NA 4 NA Lung disease – N NA 3 NA Gynaecomastia - N NA NA 1 Non-specified allergy – N 13 7 0 Eligible to start or titrate treatment by criteria A – N (%) 36 (47) 131 (75) 123 (80) 55 (80) 190 (90) 109 (90) 115 (68) 230 (82) Eligibile to start or titrate treatment by criteria B – N (%) 28 (37) 82 (47) 83 (54) 19 (28) 52 (25) 26 (22) 82 (49) 156 (55) a – criteria derived from ESC HF guidelines; b – criteria based on higher SBP and HR cut-offs. S0 – not taking the treatment; S1-3 - steps of titration as per supplementary table 1 derived from ESC HF guidelines. Abbreviations used: ESC – European Society of Cardiology; HF – heart failure; ACEI – angiotensin converting enzyme inhibitor; ARB – angiotensin receptor blocker; MRA – mineralocorticoid receptor antagonist; SBP – systolic blood pressure; eGFR – estimated glomerular filtration rateAbstract 117 Figure 1Abstract 117 Figure 2ConclusionMost patients admitted for heart failure are eligible for initiation of life prolonging medications prior to discharge. A hospital admission may be a common missed opportunity to improve treatment for HeFREF.Conflict of Interestnone