Original ResearchPrescribing trends for management of congestive heart failure from 2002 to 2004
Introduction
In the United States, congestive heart failure (CHF) is a common cardiovascular condition with approximately 5,700,000 individuals diagnosed in 2006.1 Complications associated with heart failure include increased emergency room visits, hospitalizations, and a risk for sudden cardiac death. In 2005, CHF was noted as the second most heart-related condition listed as the reason for admission to the hospital through the emergency department.1, 2 Thus, the appropriate treatment of CHF is essential for those diagnosed with this disease.
Similar to the treatment of other diseases, the use of prescription drugs is a vital part of the management of CHF. On the basis of the symptoms and tolerance to CHF-related medications, pharmacological regimens may vary among patients.3 Commonly used prescription drug classes used to treat CHF include diuretics, beta-blockers, angiotensin-converting enzyme inhibitors (ACE-Is), angiotensin receptor blockers (ARBs), and cardiac glycosides.3, 4, 5
Although there are numerous pharmacological agents available, the underuse of prescription drugs to aid in the management of CHF is startling.6 The ACE-Is are recommended for all heart failure patients unless contraindicated.3 The ACE-Is have been found to be an acceptable pharmacotherapy for 80-90% of the CHF patients and are being used more often because of their mortality benefits.5, 7 The Cooperative North Scandinavian Enalapril Survival Study Trial was a multicenter, double-blind, placebo-controlled trial that evaluated the effect of ACE-Is on the prognosis of the patients diagnosed with severe CHF.8 The patients were assigned to receive enalapril (2.5-40 mg per day), while continuing their conventional management for heart failure. At the end of 6 months, the crude mortality at the end of 6 months was 26% in the enalapril group and was 44% in the placebo group, a 40% reduction (P = .002). At 1 year, the mortality in the enalapril group was reduced by 31% (P = .001). Nevertheless, ACE-Is are only prescribed for less than half of all the CHF patients.5
Pharmaceutical agents that are currently highly recommended for the management of CHF may have not been recommended in the past. Drug therapies traditionally thought of as contraindicated in the management of CHF, such as beta-blockers, have become acceptable treatment options for the CHF patients.3 Currently, beta-blockers are major component of the management of heart failure.3 Beta-blockers are indicated in most of the patients diagnosed with CHF because of significant reduction in both mortality and morbidity.3 The recommended management of CHF has changed frequently. Thus, it would be interesting to investigate if clinical practice correlates with clinical recommendations for the management of CHF. Therefore, the objective of this study was to examine CHF-related prescription trends in the United States over a 3-year period. The purpose of the study was to analyze and gain a greater understanding of recent drug therapy trends in the United States.
Section snippets
National Hospital/Ambulatory Medical Care Survey
The National Ambulatory Medical Care Survey (NAMCS) and both divisions (outpatient and emergency department) of the National Hospital Ambulatory Medical Care Survey (NHAMCS) data sets are available online at the National Center for Health Statistics (NCHS) Web site.9 NAMCS examines patient's office visits from a national sample of office-based physicians. This survey uses a multistage probability design with the first stage involving primary sampling units representing locations in the United
Study population
Table 2 reports the weighted study population demographics and their individual strata. In summary, the descriptive statistical evaluation found that 56.2% of the study population were female; the study population age-group category associated with the highest percentage of medical visits was the ≥75 years age group (54.0%). Additionally, 81.8% of the study patients were Caucasian (White). The most frequent payment source for the patient's medical care was Medicare (65.6%). Similarly, the most
Discussion
The management of CHF should include the use of pharmacological agents, such as ACE-I and beta-blockers.3 However, an analysis of ambulatory care provided to the patients diagnosed with CHF report that there is an underutilization of ACE-Is and beta-blockers in the management of CHF. A study conducted in 1994 found about 22% of the 2777 managed care patients with a CHF diagnosis were untreated at the time.4 These findings are similar to the results reported within this study. The study reported
Conclusion
Over one-quarter of the US CHF population were not treated with any CHF-related medications during 2002-2004. More than half of these CHF patients who were receiving therapy were on 1 or 2 CHF-related medications. Most of these patients received a loop diuretic, with beta-blockers being the second most commonly prescribed CHF-related medication for the management of CHF.
Similar to previous findings, the study reports underutilization of ACE-Is (16%) in CHF management in the US ambulatory care
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