Research published in JACC: Heart Failure Nov. 6 uncovered a worrying statistic in cardiology: Older patients who are hospitalized for heart failure could experience as much as a 12% increase in the number of HF-exacerbating medications they’re prescribed between admission and hospital discharge.
In 2016, the American Heart Association published a comprehensive list of medications research has suggested might exacerbate, or induce, heart failure. The 70-plus-item roster was extensive, including prescription drugs such as anthracyclines, antipsychotics, hematologic agents, stimulants, cancer agents and calcium channel blockers.
Heart failure-exacerbating medications, by definition, could result in poor outcomes for people with HF and could be a valuable target for future risk reduction in the population. The problem? We’re not sure how often those drugs are prescribed to vulnerable, older patients with HF, and without that knowledge it’s tough to make any solid recommendations.
Parag Goyal, MD, MSc, an assistant professor of medicine in the division of cardiology at Weill Cornell Medicine, and colleagues examined a cohort of Medicare beneficiaries aged 65 and up who were hospitalized between 2003 and 2014 for heart failure. All patients were tracked via the REGARDS (Reasons for Geographic and Racial Differences in Stroke) registry.
The authors used the AHA’s list of major HF-exacerbating medications for their research, working to characterize prescribing patterns at hospital admission and discharge and examine any changes during that period of hospitalization. Harmful prescribing practice following HF hospitalization was defined as either the continuation of HF-exacerbating medications or an increase in the number of HF-exacerbating medications a person was prescribed between admission and discharge.
Among 558 patients in the study population, 18% reported a decrease in the number of HF-exacerbating medications between admission and discharge, 19% remained on the same number of meds and 12% saw an increase in their prescriptions. Multivariable logistic regression revealed that a diabetes diagnosis increased a person’s risk of being prescribed harmful medications by 1.8-fold.
Hospital size was also a big determinant of prescribing patterns, with smaller hospitals linked to a 1.93-fold higher risk of harmful prescribing practices.
“Our study found that almost half of older adults hospitalized with HF were taking a medication that can worsen HF at the time of hospital admission,” Goyal et al. wrote in their analysis. “There are several factors that can contribute to HF exacerbations that have garnered attention in HF literature; these include ischemic and arrhythmias, dietary indiscretion, medication noncompliance and stressors like infection. Our findings identify another potential contributor that is perhaps more common than has been appreciated—HF-exacerbating medications.”
The team said a major strength of their study was the fact that REGARDS data is largely generalizable, meaning their findings can likely be extrapolated to other populations. People with diabetes and those admitted to smaller hospitals seem to be at the highest risk for experiencing potentially harmful prescribing patterns, but all HF patients are at some kind of risk, suggesting we need better strategies to improve safe prescribing practices in the U.S.
“Identifying and discontinuing medications that can exacerbate heart failure has largely been overlooked,” Goyal and colleagues said. “To improve safe prescribing practice among adults hospitalized for heart failure, there is a need to develop strategies to identify and discontinue potentially harmful medications.”