Lack of adherence in heart failure therapy

Educate and monitor to improve results

When research suggests changes in standard medical practice, the public health community expects physicians and hospitals to adopt the new way and help improve patient outcomes.

But occasionally, as one study recently found, the medical community is very slow in adopting new treatment recommendations.

A good example of this is what has happened with hospitalized heart failure patients who are eligible for aldosterone antagonist therapy, according to a large database study, published in the Journal of the American Medical Association.1

The study found more than 12,000 patients who were eligible for this therapy, which research has shown would have improved their health outcomes. But only about one-third of these patients had received the therapy, which was recommended in several national guidelines.1

The research was limited by what physicians had documented with regard to contraindications, says Nancy M. Albert, PhD, CCNS, CCRN, NE-BC, FAHA, FCCM, director of nursing research and innovation in the Nursing Institute, and a clinical nurse specialist at the Kaufman Center for Heart Failure in Cleveland.

"Maybe a patient had a contraindication, and the doctor knew it but didn't document it," Albert says. "If they didn't document a contraindication with therapy, we would assume the patient was eligible to receive therapy."

The analysis began in January 2005, and continued through December 2007, and there was a steady trend from baseline of improvement in the guideline-recommended use of aldosterone antagonist therapy from 28%, when the study began, to 34% when it ended, Albert says.

"The American Heart Association and American Cardiology Association gave their stamp of approval for using aldosterone in patients in 2005," Albert says. So investigators expected to see increased use of aldosterone antagonist therapy after the guidelines were updated. But they were surprised it was only a small increase, she adds.

This lackluster response to changing to using aldosterone antagonist therapy might have been due partly to a small discrepancy in how the guidelines were worded in 2005, Albert says.

"The guidelines should have said the treatment was recommended, but instead said it was reasonable to use an aldosterone antagonist, and that doesn't have as strong a connotation," she explains.

Although a correction was published in 2006, it's possible that many physicians didn't see the correction, she adds.

Also, none of the national performance measures for hospitalized heart failure patients include aldosterone antagonist therapy as a core measure yet, Albert notes."It could be that hospitals were so focused on doing what they had to do based on The Joint Commission's performance measures and other expectations that they didn't take the next step of doing what was right based on the guidelines," she says.

Another factor is that one aldosterone antagonist is a generic drug that has been available as a potassium-sparing diuretic for years, Albert says.

"When we use it as an aldosterone antagonist, it's at a different dosage and it's for a different reason," she says. "Because the drug has been available for many years, there has been no drug company marketing of the drug, so maybe lack of use is that it's out of sight and out of mind."

Some physicians might have been reluctant to prescribe aldosterone antagonist therapy because of the drug's side effect profile, Albert says.

If the patient is already on some other therapies that are used to treat heart failure (such as an ACE inhibitor or angiotensin receptor blocker), they might have a higher risk of increased serum potassium and creatinine levels, she explains.

"So, maybe some health care providers were focusing on providing ACE-1 or ARB therapies, and maybe they had intended to start aldosterone antagonist therapy after the patient went home," she says.

The database did not yield information about therapies initiated after discharge, she adds.

The point is that while there are numerous reasons why providers might not have followed the national guidelines, the fact is that for most patients deemed eligible for the treatment, the guidelines should have been followed, leading to improved patient outcomes over time, Albert says.

Since this is an area that has fallen through the cracks, it would be a worthwhile quality improvement project for discharge planners to raise awareness about the treatment and include information about aldosterone antagonists in discharge planning paperwork for patients who meet criteria for use, he notes.

"Hospitals could monitor the use of the therapy in patients with systolic heart failure," Albert says. "If you have a registry or database, then you could keep track of your own data, and over time you should see the frequency of aldosterone antagonist use increase in patients who meet recommended criteria for receiving it."


1. Albert NM, Yancy CW, Liang L, et al. Use of aldosterone antagonists in heart failure. JAMA. 2009;302(15):1658-1665.