HF Admissions Often Come With Exacerbating Meds

Medications that can worsen heart failure (HF) are often continued or even initiated during heart failure hospitalizations, a study showed.

Fully 49% of patients hospitalized for HF were prescribed HF-exacerbating medications at some point prior to discharge, and for 12% the number of such drugs increased during the hospitalization, according to Parag Goyal, MD, of Weill Cornell Medicine in New York City, and colleagues.

Among the major exacerbating agents listed in a 2016 guideline from the American Heart Association, the most common administered to the study sample were albuterol, metformin, nonsteroidal anti-inflammatory drugs, and diltiazem, Goyal’s team reported in JACC: Heart Failure.

“This observation is highly concerning given that this occurred among hospitalizations for HF — a scenario in which an investigation into the cause of HF is paramount to preventing further hospitalizations,” the authors said.

“There are several factors that can contribute to HF exacerbations that have garnered attention in the HF literature; these include ischemia 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.”

Patients were taking a median of nine such medications at hospital admission and ten at discharge.

It was “concerning” that albuterol was being prescribed in one out of four discharges, Goyal’s group noted. “On the other hand, albuterol is first-line therapy for COPD [chronic obstructive pulmonary disease] and asthma, which together have a high prevalence in older adults with heart failure (>30% in this cohort). To complicate matters, there are limited alternative agents.”

The study was based on 558 Medicare beneficiaries (median age 76, 44% women, 34% black) who had been hospitalized for heart failure in 2003-2014. They were selected from the larger REGARDS cohort of more than 30,000 people from diverse geographic regions.

Two predictors emerged for the potentially harmful practice of prescribing HF-exacerbating agents: diabetes (OR 1.8, 95% CI 1.18-2.75) and small hospital size (OR 1.93, 95% CI 1.18-3.16).

Notably, in the case of diabetes, medications such as thiazolidinediones and dipeptidyl peptidase-4 inhibitors may actually be harmful in heart failure.

“Simply stopping these agents to treat and subsequently prevent a future HF exacerbation may not be the optimal strategy, as this can worsen glucose control and thus worsen outcomes. However, switching to other less-offending agents, when feasible, might be a reasonable approach to adopt,” Goyal and colleagues suggested. It’s unknown if sodium glucose cotransporter-2 inhibitors, for example, would be a better choice.

The authors cautioned that their observational study precludes any determination of causality.

Nevertheless, the data highlight an ongoing need to develop strategies to improve safe prescribing practice for heart failure patients, they emphasized. There also needs to be more research on optimal treatment for heart failure patients with COPD or asthma, they said.

“Future study should examine whether failure to identify and discontinue HF-exacerbating medications is a contributor to adverse post-hospitalization outcomes, which have been difficult to improve,” the investigators added.