Factors influencing treatment preferences in the patients with acute heart failure with depressed ejection fraction

Cumhuriyet Tıp Dergisi Cumhuriyet Medical Journal Cumhuriyet Tıp Derg 2011; 33: 293-298 Cumhuriyet Med J 2011; 33: 293-298 Original research-Orijinal araştırma Factors influencing treatment preferences in the patients with acute heart failure with depressed ejection fraction Düşük ejeksiyon fraksiyonu olan akut kalp yetmezliği hastalarında tedavi seçeneklerini etkileyen faktörler Meltem Refiker Ege*, Yeşim Güray, Burcu Demirkan, Hatice Şaşmaz, Mehmet Birhan Yılmaz, Şule Korkmaz Cardiology Clinic (M. R. Ege, MD.), Kavaklidere Umut Hospital, TR-06660 Ankara, Cardiology Clinic (Y. Güray, MD., B. Demirkan, MD., Assoc. Prof. H. Şaşmaz, MD., Assoc. Prof. Ş Korkmaz, MD.), Ankara Yüksek İhtisas Teaching and Research Hospital, TR-06100 Ankara, Department of Cardiology (Assoc. Prof. M. B. Yılmaz, MD), Sivas Cumhuriyet University, School of Medicine, TR-58140 Sivas Abstract Aim. Systolic heart failure (HF) is an important health problem with considerable mortality and morbidity. We aimed to investigate factors influencing initiation (prescription) of HF drugs within the hospital. Method. Hospital records of consecutive 456 patients, hospitalized (first hospitalizations) and treated for acute HF (ejection fraction <40%) were retrospectively reviewed. In-hospital treatments were considered irrespective of previous or discharge treatments. Results. Patients with impaired renal function were administered beta blockers more frequently compared to those without impaired GFR. Functional class did not seem to influence starting of ACE inhibitors or beta blockers. Those with ischemic HF were given ACE inhibitors less frequently compared to those with nonischemic HF. Those with permanent AF were less frequently administered aspirin and ACE inhibitors compared to those without. Elderly patients (≥65 years) were not different from younger ones in terms of prescription choices including ACE inhibitor, beta blocker, and spironolactone. Patients with anemia were not different from those without anemia in terms of prescription of ACE inhibitors, beta blockers and spironolactone. Conclusion. We think that recognizing factors that drive physicians to initiate or continue drugs in systolic HF is important in making risk stratification accurately and in modifying prognosis. Keywords: Acute systolic heart failure, drugs, subgroup Özet Amaç. Sistolik kalp yetmezliği mortalite ve morbidite açısından önemli bir sağlık problemidir. Çalışmanın amacı, kalp yetmezliği nedeni ile hastaneye başvuran hastalarda kalp yetmezliği ilaçlarının başlanmasını etkileyen faktörleri araştırmaktı. Yöntem. Akut kalp yetmezliği nedeni ile ilk kez hastaneye başvuran ejeksiyon fraksiyonu < % 40 altında olan 456 ardışık hastanın hastane kayıtları retrospektif olarak incelendi. Hospitalizasyon sırasındaki tedaviler, daha önceki tedavilerden ve taburculuk sırasındaki tedavilerden bağımsız olarak değerlendirildi. Bulgular. Beta bloker kullanımı renal fonksiyonları bozuk olan hastalarda GFR si normal olan hastalara kıyasla daha fazla idi. ACE inhibitörleri ile beta blokerlerin başlanmasında fonksiyonel kapasitenin bir etkisi yoktu. İskemik kalp yetmezliği olan hastalarda ACE inhibitörü kullanımı iskemik olmayan kalp yetmezlikli hastalara göre daha azdı. Permanent AF si olan hasta grubunda olmayan hastalara kıyasla aspirin ve ACE inhibitörlerinin kullanımı daha düşüktü. ACE inhibitörü, beta bloker ve spiranalakton kullanımı açısından yaşlı (≥ 65 yaş) ve genç hastalar arasında fark yoktu. ACE inhibitörü, beta blokör ve spiranalakton reçete edilmesinde anemisi olan ve olmayan hastalar arasında fark saptanmadı. Sonuç. Sistolik kalp yetmezliğinde ilaç başlanmasını ve tedavinin devamını etkileyen faktörlerin fark edilmesi hastaların risklerinin belirlenmesinde ve prognozun değiştirilmesinde önemli bir etken olabilir. Anahtar sözcükler: Akut sistolik kalp yetmezliği, ilaçlar, altgruplar 294 Geliş tarihi/Received: April 07, 2010; Kabul tarihi/Accepted: August 3, 2011 *Corresponding author: Meltem Refiker Ege, MD., Kardiyoloji Kliniği, Ege, Kavaklıdere Umut Hastanesi, TR-06100 Ankara. E-mail: Introduction Systolic heart failure (HF) is associated with increased morbidity and mortality in the general population, particularly in the elderly [1-3]. Despite significant improvements in morbidity and mortality via several agents [4], optimal therapy in real life practice is far from ideal. Several reasons such as age, sex, accompanying diseases, hypertension, congestion, physician’s perception, and racial differences may have an impact on it [5]. On the other hand, age seems to influence therapeutic choices. Since, older patients with HF are more likely to have other comorbid conditions that may interact with prescribed medications, older patients with HF seems to be undertreated compared to their younger counterparts [6]. Furthermore, several disease states frequently complicate the course of HF and hence modify therapeutic choices such as renal failure, anemia [7-9]. In this study, we investigated the factors influencing initiation (or continuation) of inhospital treatment among patients who were hospitalized with acute systolic heart failure for the first time in their lives in a retrospective cohort. Material and methods Hospital records of consecutive 456 patients (329 male, 127 female) with a mean age of 57.5±15.5 years, hospitalized (first hospitalizations) and treated for acute HF (ejection fraction <40%) were retrospectively reviewed. In-hospital administration of drugs (initiation or continuation) was considered irrespective of previous or discharge treatments. All patients were under the care of a cardiologist. Hypertension (HT) was defined as having blood pressure >140/90 mmHg or being on treatment, diabetes mellitus (DM) was defined as having fasting blood glucose of >125 mg/dL or being on antidiabetic medication, current smoking was accepted to indicate smoking status. Patients having left ventricular (LV) ejection fraction (EF) >40%, creatinine level >3 mg/dl, severe dysfunction of liver function tests (>3 times upper limit of normal), asthma, patients having myocardial infarction or acute coronary syndrome within the last month and patients who were previously hospitalized with acute decompensation of HF were excluded from the study. Besides, patients who were designated to have NYHA Class I symptoms at admission were excluded due to the possibility of misleading results. Patients with incomplete and/or complete bundle branch block were considered as having bundle branch block. Ejection fraction was measured by echocardiography via Modified Simpson’s method by blinded authors within 48 hours of admission. Patients were classified into two as those with permanent atrial fibrillation (AF) and those who were not. Concerning in-hospital prescriptions, patients were subclassified into two as those who were started a specific drug (intravenous diuretic, oral beta blocker, oral ACE inhibitor, spironolactone, intravenous nitrate (...truncated)