JAMA: 1 in 4 ICD patients don't receive optimal medical therapy

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The administration of optimal medical therapy (OMT) to patients with implantable cardioverter-defibrillators (ICDs) may decrease mortality; however, according to a research letter published online Nov. 14 in the Journal of the American Medical Association, nearly one in four of these patients are not prescribed beta-blockers or ACE inhibitors/ARBs.

“Current guidelines predicate primary prevention cardioverter-defibrillator (ICD) implantation on patients receiving 'optimal medical therapy,' defined as use of both beta-blocker and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEI/ARB) in the absence of contraindications,” Amy Leigh Miller, MD, PhD, of Brigham and Women’s Hospital in Boston, and colleagues wrote. “These recommendations promote clinical optimization of patients with low left ventricular ejection fraction (LVEF) as well as cost-effective allocation of high-cost device therapy.”

Within the letter, Miller and colleagues evaluated the national patterns of OMT use among first-time ICD recipients in the real-world setting. Miller and colleagues used the ICD registry to do so. The ICD registry held records of ICD implantations between Jan. 1, 2007, to June 30, 2009, and included 175,757 patients who underwent a first-time ICD implantation.

Of the 175,757 initial ICD recipients, 45,240 were eligible for but did not receive OMT. The rate of OMT prescriptions by site ranged from 0 to 100 percent with a median of 73.5 percent. Patients who received OMT were more likely to be younger, have commercial insurance and be diagnosed with hypertension.

Of patients who underwent CABG surgery, 65.7 percent were discharged on OMT. Similarly, 75.3 percent of patients who underwent a PCI procedure were discharged on OMT. The researchers reported OMT use to be highest in government hospital and lowest at private or community hospitals. Academic teaching hospitals saw the highest rate of OMT use.

Other factors that led to higher OMT use included PCI during admission, being treated at a teaching hospital, a history of hypertension and a cardiovascular indication for admission. ACE inhibitors and ARBs were not prescribed in 18.7 percent of patients with low left ventricular ejection fractions, and 10.7 percent were not prescribed beta-blockers.

“Although medical therapy optimization reduces mortality, the risks of heart failure decompensation and ventricular arrhythmias requiring shocks, one in four ICD recipients with an LVEF of 35 percent or lower are not prescribed beta-blockers and ACEI/ARBs,” the authors wrote.

“While our study cannot distinguish between true but undocumented contraindications in patients and healthcare provider reluctance to challenge patients deemed at risk of developing an adverse reaction, it underscores the need for increased vigilance for treatment opportunities.”

The authors noted that electronic decision support systems and standardizing order sets could help close these types of care gaps. Additionally, involving a medical cardiologist in the peri-implantation setting could help identify appropriate, medically optimized ICD candidates and maximize OMT adherence.

“[D]espite well-proven benefits and guideline recommendations, gaps in medical therapy optimization of ICD recipients persist,” Miller et al concluded. “These results underscore the need for dedicated strategies, optimized quality of care and improved cost-effectiveness of care for patients with heart failure.”