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In-hospital management of disease modifying drugs in heart failure with reduced ejection fraction - an opportunity to improve?

Session Poster Session 2

Speaker Francisco Adragao

Event : Heart Failure 2019

  • Topic : heart failure
  • Sub-topic : Treatment
  • Session type : Poster Session

Authors : I Nabais (Cascais,PT), I Costa (Lisbon,PT), F Adragao (Portimão,PT), I Egidio (Lisbon,PT), P Moniz (Lisbon,PT), L Campos (Lisbon,PT), I Araujo (Lisbon,PT), C Fonseca (Lisbon,PT)

I Nabais1 , I Costa2 , F Adragao3 , I Egidio4 , P Moniz5 , L Campos4 , I Araujo5 , C Fonseca5 , 1Hospital de Cascais, Medicina Interna - Cascais - Portugal , 2Hospital de São José, Medicina Interna - Lisbon - Portugal , 3Centro Hospitalar Universitário do Algarve - Hospital de Portimão, Medicina Interna - Portimão - Portugal , 4Hospital de Sao Francisco Xavier, Medicina Interna - Lisbon - Portugal , 5Hospital de Sao Francisco Xavier, Unidade de Insuficiência Cardíaca - Lisbon - Portugal ,

Chronic Heart Failure – Treatment

Introduction: Heart failure (HF) is a syndrome with high morbimortality and its prevalence continues to grow. New therapeutic options are an opportunity to change the natural history of the disease. Guidelines recommend in-hospital maintenance or initiation of all disease-modifying drugs (DMD), with titration as much as possible before discharge.

Objective: To analyse in-hospital management of DMD in HF with reduced ejection fraction (HFrEF) patients admitted in an Acute Heart Failure Unit (AHFU). 

Methods: Retrospective study of consecutive hospitalizations due to acutely decompensated HF, over a year, examining hospital databases. HFrEF patients discharged from the AHFU were selected to evaluate medication at admission, in-hospital and at discharge.

Results: From the 181 AHFU admitted patients, 76 HFrEF were included. At admission 68.4% were on renin-angiotensine-aldosterone inhibitor (RASi) - 50.0% ACEi, 9.2% ARB, 9.2% ARNI; 72.4% on beta blocker (BB) and 65.8% on aldosterone antagonists (ARM). At discharge 77.6% were on RASi - 57.9% ACEi; 9.2% ARB; 10.5% ARNI; 85.5% BB and 77.6% ARM; 57.9% were on triple DMD therapy and 10.5% on Ivabradine. Regarding ACEi: 34.1% started, 18.2% increased and 27.3% maintained ambulatory dose; Regarding ARB: 14.3% started, 14.3% increased, 42.9% maintained ambulatory dose. Regarding ARNI: 25% started, 23.5% increased 50% maintained ambulatory dose. Although during hospitalization all DMD were titrated to patients maximum tolerated dose, at discharge most patients on RASi (83.1%) and BB (80.0%) were not on maximum recommended doses according to guidelines, while on ARM only few patients (27.1%) didn’t reach maximum doses. Very few patients needed to reduce or suspend DMD medication at discharge - 5.8% reduced and 21.2% suspended RASi, mainly due to low blood pressure (50.0%) and renal disease (30.0%); 12.7% reduced and 10.9% suspended BB mainly due to low blood pressure (38.9%) and bradycardia (22.2%); 6% both reduced and suspended ARM mainly due to renal disease (60.0%).

Conclusion: While being a predictor of bad prognosis, hospitalization was an opportunity to optimize HFrEF treatment. At discharge patients’ DMDs maximum tolerated doses were frequently inferior to guideline’s recommended maximum dosages. Although in line with other real-life registries and even trials, titration should always be re-challenged in an early post-discharge assessment.

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