Top Causes of Heart Failure Admissions, Drug Safety Concerns

Heart failure is a common significant disorder in the United States.  Exacerbations of heart failure symptoms accounts for more than 1 million hospitalizations yearly with an estimated socioeconomic cost of $11 Billion.^1-2  Exacerbations can be caused by many factors, not the least of which are medications.  The importance of the contributions of medications to exacerbations can be stressed by the fact that  guideline-directed medical therapy is a quality metric in the United States, attached to hospital reimbursement for a heart failure admission.³ The American Heart Association lists medications that could exacerbate heart failure.⁴ These agents are explained in reference 4, but in brief include the categories of NSAIDs, anesthesia medications, diabetes mellitus medications (biguanides and dipeptidyl peptidase-4 inhibitors), several antiarrhythmic agents, calcium channel blockers, azole antifungals, many anti-cancer medications, stimulants and antidepressants, and rheumatological agents.  To date, however, there is limited data on the extent of these medications prescribed in the hospital to patients with heart failure. 

A recent study sought to describe the patterns of heart failure—exacerbating medications used among older adults hospitalized for heart failure.⁵ Medicare beneficiary’s ≥ 65 years of age with a hospitalization from 2003 to 2014 were assessed from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study.  The study found 558 unique individuals, mean age 76 years of age, 44% female, and 34% black.  Eighteen percent experienced a decrease in the number of HF-exacerbating medications between admission and discharge, 19% remained the same, and 12% experienced an increase.  Identifiers from multivariable logistic regression analysis showed that diabetes and small hospital size were the strongest determinants of harmful practice patterns.  The drug most added was albuterol, and the drug class withdrawn the most were NSAIDs, followed by metformin and thiazolidinediones.

This observational study provides some evidence for careful oversight of new medications added to patients hospitalized with a heart failure exacerbations.  Although some drugs may be beneficial, many are not.  Switching from less-offending agents, when reasonable, is important.   

The critical take home message is that pharmacists need to be vigilant on medication administration records for all patients and intervene when necessary to avoid unnecessary drug misadventuring, especially in heart failure.

Mark A. Munger, PharmD, FCCP, FACC, is a professor of pharmacotherapy and adjunct professor of internal medicine, at the University of Utah, where he also serves as the associate dean of Academic Affairs for the College of Pharmacy. 

References:

1. Heart Failure Facts. Accessed 12/2019
2. Jackson SL, Tong X, King RJ, et al. National burden of heart failure events in the United States 2006 to 2014. Circulation: Heart Failure 2018;11:e004873
3. Bonow RO, Geniats TG, Beam CT, et al. ACCF/AHA/AMA-PCPI 2011 performance measures for adults with heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association—Physician Consortium for Performance Improvement. Circulation 2012;125:2382-401.
4. Page RL, 2^nd, O’Bryant CL, Cheng D, et al. Drugs that may cause exacerbate heart failure: a scientific statement from the American Heart Association. Circulation 2016;134:e32-69.
5. Goyal P, Kneifati-Hayek J, Archambault A, et al. Prescribing patterns of heart failure—exacerbating medications following a heart failure hospitalization. JACC-Heart Failure 2019;doi.org/10.106/j.jchf.2019;08.007.