Optimal drug dosing after heart failure extends patients’ careers

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Patients who receive target or near-target doses of evidence-based medicine (EBM) are more likely to continue working after a heart failure hospitalization, according to a study of Danish individuals published Dec. 6 in JACC: Heart Failure.

While drugs and typically evaluated based on their clinical outcomes, “they do not reflect the whole burden of HF (heart failure) on the individual, his or her family and care-givers, or on society,” wrote lead author Rasmus Rorth, MD, with the department of cardiology at the University of Copenhagen, and colleagues. “A patient’s ability to work reflects both the direct and indirect consequences and costs of HF.”

Rorth et al. identified 10,185 patients who were in the workforce one year after their first hospitalization for heart failure. Of those, 7,561 (74 percent) were prescribed at least one of the “cornerstone” treatments for heart failure—beta-blockers or renin angiotensin system inhibitors (RASi).

The researchers set the baseline for their study at one year after index hospitalization and evaluated whether medical dosage was associated with subsequent career detachment. The target dose was assigned a score of 1 for each medication, giving each patient the possibility of having a score between 0 and 2 for the fraction of target-dose EBM they received.

Over a median follow-up of 727 days, 36 percent of the patients became detached from the workforce.

Compared to individuals receiving the lowest fraction of medication, people prescribed more EBM had decreased risk for workforce detachment as follows: 13 percent for the target dose, 15 percent for an EBM score between 1 and 2, and 8 percent for EBM dosage from 0.5 to 1.

In all, only 47 percent of the patients in the workforce one year after heart failure hospitalization were prescribed target or near-target dosages of EBM. Younger patients, males and those with higher education levels were more likely to remain employed.

“Our results should be interpreted with some caution, as the inability to up-titrate EBM could be due to intolerance of larger doses because of more severe cardiac as well as noncardiac underlying disease,” the researchers noted. “However, this is not a likely explanation in our study as comorbidities were evenly distributed across score groups and use of diuretic agents and MRAs (mineralocorticoid receptor antagonists) were more common among patients in the groups with a higher treatment score.”

Among the patients who experienced workforce detachment, 61 percent went on paid sick leave, 22 percent took early retirement and 12 percent received disability pension. No patients in the study were old enough to receive ordinary retirement pension, which is available to Danish residents beginning at age 65.

Consistent with other cardiovascular medications, women were less likely to receive optimal doses of beta-blockers and RASi, despite no clinical evidence of differential effects. They were also less likely to stay employed than men.

“Although our data do not enable us to examine exact reasons for this difference, it can be speculated that men may be under greater pressure than women to keep their job for economic reasons, and working status may be more important to the male identity,” Rorth et al. wrote. “The motivation to keep working might also change with age. Older patients closer to retirement age might be more willing to leave the workforce due to lack of necessity and not because of poor performance status.”

A primary limitation of the research was the lack of clinical information available, which could have accounted for dosage differences applied to individual patients. In addition, the authors relied on the strength and frequency of patients’ prescriptions to estimate medical dosage, but they didn’t have a way to account for patient adherence.

In an accompanying editorial, Marc A. Silver, MD, with Advocate Christ Medical Center in Oak Lawn, Illinois, said maintaining a societal connection in all areas of life is essential for heart failure patients.

“For most, if not all of our patients we need to be sensitive to their risk of ‘detachment’ in general,” he wrote. “It may be workforce, or family, or going to church or the market, or simply engaging in daily activity forms of detachment.

“We must add engagement or re-engagement of the patient into their community to a goal for all of our patients with heart failure. Similarly, we need to be vigilant in making sure patients reach target doses of their EBM and understand the ubiquitous ‘creep’ away from target doses of life-saving therapies.”