Compliance with clinical practice guidelines for the treatment and optimization of therapy in heart failure patients in outpatient medicine clinics MaryAnn E. Birch, Pharm.D., Emily K. McCoy, Pharm.D., Bradley M. Wright, Pharm.D., BCPS, Kristi Kelley, Pharm.D., BCPS, CDE The American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) clinical guidelines address the pharmacological treatment of heart failure (HF) Beta blockers and angiotensin converting enzyme inhibitors (ACEi) are recommended if patients have: – Current or prior symptoms of HF – Ejection fraction (EF) less than 40 percent – No contraindications Target doses are recommended for both the beta blockers and the ACE inhibitors The addition of these agents in indicated patients has been shown to decrease the rates morbidity and mortality The purpose of this interim analysis is to determine guideline adherence in regards to ACE inhibitor and beta-blocker therapy Primary Objective To determine the percentage of patients being treated with ACE inhibitors and beta-blockers Secondary Objectives To determine the percentage of patients at target doses of these agents To evaluate any barriers that have prevented optimization It is expected that there will be some divergence from the recommended pharmacological therapy It is presumed that barriers preventing the optimization of therapy may be identified Hyperkalemia Symptomatic bradycardia Deterioration of renal function Angioedema Patient adherence Reliance on cardiology follow up  In this preliminary review, both beta blockers and ACE inhibitors/ARBs have low rates of optimization  Beta blockers are less frequently optimized than ACE inhibitors  In the majority of cases there is not an obvious, documented barrier to initiating or optimizing therapy with either class Background Conclusions  Three patients (9%) had obvious barriers to treatment with a beta blocker − Reported dizziness/orthostatic hypotension impeding optimization (2 patients) − HF exacerbation requiring discontinuation  Three patients (3%) had a contraindication to treatment with an ACE inhibitor due to deteriorating renal function and/or hyperkalemia  Optimization of therapy was not achieved in one patient due to documented poor adherence.  Seventy-five patients (77%) have been referred to a cardiology clinic  Eighty-one patients (83%) were on diuretic therapy with loop diuretics  Twelve patients (12%) were being treated with aldosterone antagonists − Three (25%) of these patients were optimized on ACE inhibitor/Beta blocker therapy  Ten patients were being treated with hydralazine/isosorbide dinitrate therapy − None of these patients were optimized on ACE inhibitor/beta blocker therapy Authors of this presentation have the following to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation: Brad Wright is currently receiving funding from Novartis Pharmaceuticals; all other authors have nothing to disclose. Disclosure Objectives Medical charts will be reviewed retrospectively to evaluate the pharmacological therapy of patients with heart failure The sample was selected from outpatient heart failure patients who were followed at various University-affiliated outpatient primary care clinics between July 1, 2009 and July 31, 2010 Inclusion Criteria: − Ejection fraction of less than 40 − ICD-9 code for systolic heart failure Exclusion Criteria: − Diastolic heart failure − Patients 19 years of age or younger − Patients who are pregnant − Patients who are prisoners Adherence to the 2009 ACC/AHA updated treatment guidelines will be evaluated by analyzing: − Recorded medications − Dose prescribed − Contraindications to therapy Expected Outcomes Preliminary Results Recommended Target Doses Methods Figure 2 Preliminary Results Preliminary Results  After reviewing the list generated using ICD-9 codes for heart failure for 2 of 3 clinics*, ninety-eight patients were included in this preliminary analysis  Seventy-two patients (74 %) were not on optimized beta blocker therapy  Forty-nine patients (50%) were not on optimized ACE inhibitor therapy  Only 9 patients (9%) were optimized in both drug classes Bisoprolol10mg daily Carvedilol25mg BID Carvedilol ER80mg daily Metoprolol succinate 200mg daily Beta Blockers ACE Inhibitors Captopril50-100mg TID Enalapril10-20mg BID Fosinopril20-40mg daily Lisinopril20-40mg daily Quinapril10-20mg BID Ramipril5-10mg daily Trandolapril4mg daily *Patients from two of three clinics involved with this research Figure 1 Preliminary Results