More Than Half of All HF Patients Take 10 or More Meds
Medication needs in elderly HF patients should focus on self-identified health priorities, experts contend.
At hospital discharge, 55% of patients with heart failure leave with prescriptions for 10 or more medications, a new study shows. According to the investigators, the findings are a call to action for physicians to work together to decrease the growing burden of polypharmacy.
“Communication needs to be better across disciplines, but I would argue that it also needs to be better across care settings,” senior author Parag Goyal, MD, MSc (Weill Cornell Medicine, New York, NY), told TCTMD. “When the patient is ambulatory and goes to an office visit versus when they end up in the hospital versus when they end up in rehab or a nursing home, those systems often don't communicate with one another.”
As part of the REGARDS study, Goyal and colleagues, led by Ozan Unlu, MD (Weill Cornell Medicine), reviewed medical charts for 558 adults hospitalized with HF between 2003 and 2014 at 380 US hospitals, tallying the number of medications at admission and discharge.
At admission, 84% were taking five or more medications and 42% were taking 10 or more. The study used 10 medications as the bar for polypharmacy, finding that its incidence at discharge increased from 41% in 2003-2006 to 68% in 2011-2014 (P for trend < 0.0001). The findings throughout the study were similar in patients with HF either with or without preserved ejection fraction.
Goyal said while he really was not surprised by the findings, published online last week ahead of print in Circulation: Heart Failure, he thinks they are a wake-up call about the importance of medication reconciliation to determine what each agent is achieving, whether it’s interacting with other drugs, and whether the benefits of each outweigh the risks.
“We really need people to develop strategies, processes, to optimize this sort of communication and cross-collaboration, because the systems are not in place currently,” he said. Admittedly, weighing risks versus benefits can be difficult without input from the physician who prescribed what another physician might consider unnecessary medication, Goyal and colleagues say. Determining risks and benefits also is highly dependent on a host of factors that relate not only to the type and severity of HF, but also need to be inclusive of geriatric conditions, including cognitive impairment.
Arriving on the Same Page
Among the other study findings were that medications for non-CV conditions accounted for the largest burden of polypharmacy at both admission and discharge. The top five most common non-CV medications at admission were proton pump inhibitors, electrolyte supplements, multivitamins, thyroid hormone, and selective serotonin reuptake inhibitors. In multivariable analyses, each additional comorbid condition that a patient had increased the relative risk of taking at least 10 medications at discharge by 13%.
“I think [the study] just underscores the importance of being proactive in reviewing all the medications and ensuring that we're giving the patient the best opportunity to thrive after they leave the hospital,” Goyal said.
In an accompanying editorial, Rachel Denny, DO, and Scott L. Hummel, MD (both University of Michigan, Ann Arbor), observe that “collaboration among cardiology teams, geriatricians, and pharmacists is needed for the nuanced application of algorithms, especially when treatment guidelines conflict in patients with multiple comorbidities.”
Goyal and colleagues, as well as the editorialists, also state that medication needs in older patients with HF should be focused around self-identified health priorities to achieve the outcomes that matter most to individual patients.
“Preliminary research suggests preferences can be formally elicited and documented even in busy outpatient cardiology practice settings, then later used to guide management,” Denny and Hummel write.
Unlu O, Levitan EB, Reshetnyak E, et al. Polypharmacy in older adults hospitalized for heart failure. _Circ Heart Fai_l. 2020;Epub ahead of print.
Denny R, Hummel SL. Heart failure medical management in 2020: searching for the right polypharmacy. Circ Heart Fail. 2020;Epub ahead of print.
- The study was funded by the National Institute of Neurological Disorders and Stroke and the National Institute on Aging of the National Institutes of Health.
- Unlu, Goyal, Denny, and Hummel report no relevant conflicts of interest.