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2/3 of Heart Failure Patients Don't Get Major Drug

Aldosterone Antagonists Improve Heart Failure Survival, but Only 1 in 3 Get Them
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Oct. 20, 2009 -- More than two-thirds of patients hospitalized with serious heart failure aren't prescribed an aldosterone antagonist, a recommended therapy that increases the odds of survival.

Aldosterone is a hormone that is released in the setting of heart failure. It causes salt and water retention, which can lead to worsening symptoms (such as shortness of breath and leg swelling). Aldosterone antagonists block the action of aldosterone and are a well-recognized part of heart failure treatment.

Published guidelines specifically recommend aldosterone antagonists for patients with moderate-to-severe heart failure. Aldactone and Inspira are the two aldosterone antagonists (AAs) available on the market. They’re not for every patient. But the present study shows that far too many patients who should be getting AAs are not.

The finding comes from a survey by Cleveland Clinic researcher Nancy M. Albert, PhD, RN, and colleagues, who followed up on 43,625 AA-eligible heart failure patients released from 241 U.S. hospitals from 2005 through 2007.

"Less than one-third of eligible patients hospitalized for heart failure ... received heart failure guideline-recommended aldosterone antagonist therapy," Albert and colleagues write in the study.

What's going on?

Old guidelines, in effect during the study period and only updated in 2009, said the treatment "should be considered" rather than saying it "is recommended."

Also, in some published studies there "may have been an overestimation of harm" because of the drug's potential to negatively affect kidney function, Albert and colleagues suggest.

Another problem is that AAs are well-known diuretics (water pills), which may have confused some doctors as to their more extensive mechanism of action in heart failure.

And it is possible that institution of AA therapy did not occur until patients’ other medications had been optimized in the outpatient setting.  

But failure to adhere to recommended treatment algorithms by physicians may be a major reason for low rates of AA therapy. A recent survey of European doctors showed the three main reasons they did not adhere to treatment guidelines were patient compliance, long and complexly written treatment guidelines, and time needed to get patients on all the recommended treatments.

"Given the substantial morbidity and mortality risk faced by patients hospitalized with heart failure and the established efficacy of aldosterone antagonist prescription in heart failure, a stronger uptake of [AA] therapy may be warranted," Albert and colleagues conclude.

The findings appear in the Oct. 21 issue of the Journal of the American Medical Association.

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