Vorapaxar in atherosclerotic disease management.

OBJECTIVE: To review the pharmacology, efficacy, and safety of vorapaxar, a protease activator receptor-1 (PAR-1) antagonist, in the management of atherosclerotic diseases. DATA SOURCES: Peer-reviewed clinical trials and review articles were identified from MEDLINE and Current Content database (both 1966 to December 31, 2014) using the search terms vorapaxar and protease activator receptor antagonist. STUDY SELECTION AND DATA EXTRACTION: A total of 30 clinical studies were identified (16 clinical trials, including subanalyses, 14 related to pharmacology, pharmacokinetics, and pharmacodynamics and drug interactions). DATA SYNTHESIS: Two phase III clinical trials with vorapaxar have been published. In patients with non-ST segment elevation myocardial infarction (MI), vorapaxar failed to significantly reduce the primary efficacy end point (composite of cardiovascular death, MI, stroke, recurrent ischemia with hospitalization, and urgent coronary revascularization). Conversely, in a study of secondary prevention for patients with cardiovascular disease, the composite end point of cardiovascular death, MI, or stroke was significantly reduced. In both trials, the safety end points of major/minor bleeding were increased compared with placebo. In the secondary prevention trial, an increased incidence of intracranial hemorrhage led to the exclusion of patients with a prior history of stroke. CONCLUSION: Vorapaxar is approved for use with aspirin and/or clopidogrel in the secondary prevention of cardiovascular events in stable patients with peripheral arterial disease or a history of MI. However, the addition of vorapaxar to other antiplatelets can significantly increase the risk of bleeding. It is, therefore, essential to balance the need for further reduction of risk of thrombotic event with patient's individual bleeding risk.

Assessment of prescribers' knowledge of the cost of medications.

BACKGROUND: In 2003, the World Health Organization reported that 50% of patients are adherent to long-term therapies. Frequently, the reason for a patient's nonadherence is the cost of medications. Even with prescription insurance coverage, patients may not be able to afford their medications. OBJECTIVE: To assess prescriber knowledge of the cost of commonly prescribed medications including atorvastatin, gabapentin, levofloxacin, losartan, pantoprazole, pioglitazone, and quetiapine. Secondary objectives were to evaluate how often prescribers consult a discounted drug list and a patient's prescription insurance coverage. METHODOLOGY: One hundred prescribers from the Medical University of South Carolina were surveyed from November 2010 to January 2011. Prescribers consisted of medical residents, attending physicians, fellows, nurse practitioners, and physician assistants. Wholesale prices of medications were determined using the Red Book, and prescription insurance prices were calculated from an average of the top 3 prescription insurance companies' copayments. RESULTS: Medical residents made up 72% of those surveyed, fellows 3%, attending physicians 12%, physician assistants 3%, and nurse practitioners 10%. The prescriber groups were unable to correctly determine the cost of medications of more than 50% of total possible responses. The majority of prescribers rarely asked about a patient's prescription insurance coverage or consulted a discounted drug list before writing a prescription. CONCLUSIONS: Prescribers are more likely to know the cost of medications for patients who have prescription insurance coverage versus those who do not.

Continuous versus intermittent infusion of furosemide in acute decompensated heart failure.

BACKGROUND: Despite advances in the treatment of chronic ambulatory heart failure, hospitalization rates for acute decompensated heart failure (ADHF) remain high. Although loop diuretics are used in nearly all patients with ADHF to relieve congestive symptoms, optimal dosing strategies remain poorly defined. METHODS AND RESULTS: This was a prospective, randomized, parallel-group study comparing the effectiveness of continuous intravenous (cIV) with intermittent intravenous (iIV) infusion of furosemide in 56 patients with ADHF. The dose and duration of furosemide as well as concomitant medications to treat ADHF were determined by physician preference. The primary end point of the study was net urine output (nUOP)/24 hours. Safety measures including electrolyte loss and hemodynamic instability were also assessed. Twenty-six patients received cIV and 30 patients received iIV dosing. The mean nUOP/24 hours was 2098+/-1132 mL in patients receiving cIV versus 1575+/-1100 mL in the iIV group (P=.086). The cIV group had significantly greater total urine output (tUOP) with 3726+/-1121 mL/24 hours versus 2955+/-1267 mL/24 hours in the iIV group (P=.019) and tUOP/mg furosemide with 38.0+/-31.0 mL/mg versus 22.2+/-12.5 mL/mg (P=.021). Mean weight loss was not significantly different between the groups. The cIV group experienced a shorter length of hospital stay (6.9+/-3.7 versus 10.9+/-8.3 days, P=.006). There were no differences in safety measures between the groups. CONCLUSIONS: The cIV of furosemide was well tolerated and significantly more effective than iIV for tUOP. In addition, continuous infusion appears to provide more efficient diuresis.

Barriers to clopidogrel adherence following placement of drug-eluting stents.

BACKGROUND: Nonadherence to clopidogrel after drug-eluting stent (DES) placement is associated with in-stent thrombosis and adverse cardiac events. OBJECTIVE: To identify the incidence of and barriers associated with nonadherence to clopidogrel in patients receiving DES. METHODS: Patients who received a DES between March 1, 2004, and August 31, 2005, from a single academic medical center were eligible. Telephone interviews were conducted 6 or more months following discharge. Nonadherence was defined as premature discontinuation of or less than 80% adherence to clopidogrel. Patients were asked to identify barriers to adherence. Differences between adherent and nonadherent patients were analyzed using chi(2) and t-test analysis. RESULTS: Of the 674 patients identified, 257 (38%) participated. The nonadherence rate was 20%. The majority (58%) of nonadherent patients discontinued therapy prematurely. Patients identified the main reason for discontinuation as medical barriers (18.56%), including perceived adverse effects (9.28%). The incidence of rash was higher in patients who were nonadherent (12% vs 4%; p = 0.049). Overall, 49% of patients recalled receiving discharge counseling regarding adverse effects. A financial barrier was identified by 22 (42%) patients in the nonadherent and 73 (36%) in the adherent group, of whom 64% and 52%, respectively, reported having insurance coverage for medications. Adherent patients reported higher copays ($29.69 vs $18.14; p = 0.01). CONCLUSIONS: Prospective studies should be conducted to aid in identifying patients at risk for nonadherence and possible in-stent thrombosis in order to identify interventions to improve adherence.

Key Articles and Guidelines in the Management of Heart Failure: 2018 Update.

Heart failure is one of the leading causes of hospitalizations in the United States, with >1 million admissions yearly and a 25% risk of readmissions within 1 month. In order to assist clinicians, we provide an update of the heart failure bibliography that was published in Pharmacotherapy in 2008, which followed the original bibliography published in 2004. A significant number of clinical trials and observational studies have been conducted since the early 1980s to guide management of heart failure patients. Major advances have occurred in the past 10 years, and our understanding of the diagnosis, prevention, and management of heart failure has evolved substantially during this time period. Specific areas of this review include heart failure risk factors, management of comorbid conditions, acute heart failure management, chronic heart failure management, advanced heart failure, device therapy, lifestyle modification, and medication and therapy management, including medication adherence. Key consensus guidelines and statements are also included. This bibliography of key heart failure papers aims to provide clinicians and their trainees with a valuable clinical reference resource and teaching tool that may be used to optimize the care of patients with heart failure.

Type 2 diabetes mellitus and heart failure.

Diabetes mellitus and heart failure are common comorbidities, and their prevalence has increased significantly over the past decade. We examined the relationships between diabetes and heart failure, the effect of commonly prescribed antidiabetic drugs on the development of heart failure, and the benefits and risks of recommended heart failure therapies in patients with diabetes. Compared with patients with heart failure who do not have diabetes, patients with both diabetes and heart failure have a poorer prognosis, including a 1.5-2-fold higher risk of mortality. Based on the results of randomized controlled trials, insulin and sulfonylureas do not appear to protect against or contribute to the development of new-onset heart failure, whereas metformin may modestly reduce the risk. The use of metformin in patients with established heart failure is controversial; retrospective analyses have shown that metformin may have a beneficial effect on outcomes, but there are no prospective, randomized clinical trials to support its use in this population. The thiazolidinediones, however, contribute to the development of heart failure and increase the risk of heart failure exacerbations particularly when used in combination with insulin. Recommendations for the treatment of symptomatic heart failure in patients with diabetes have been largely derived from post hoc analyses or preplanned subgroup analyses in landmark clinical trials. The data clearly support the use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers for both the prevention and treatment of symptomatic heart failure in patients with diabetes. Despite concerns regarding the potential risks of beta-blockers in patients with diabetes, these drugs have a clear mortality benefit in patients with stages B and C heart failure. Therefore, patients with diabetes should not be denied beta-blocker therapy unless there is a clear contraindication. Likewise, aldosterone receptor antagonists should be added to standard therapies in patients with stages C and D heart failure. Future heart failure studies should include a sufficiently large diabetes cohort to conduct meaningful preplanned subgroup analyses that examine the effect of proposed treatments on both heart failure-related and diabetes-related outcomes.

Prevalence of anemia in clinic patients with heart failure and cost analysis of epoetin treatment.

STUDY OBJECTIVES: To determine the prevalence of anemia in an outpatient heart failure clinic, describe the type of anemia in patients treated there, and evaluate the potential costs associated with epoetin therapy in this cohort. DESIGN: Single-center, retrospective cohort analysis (part 1) and a literature-based economic decision analysis (part 2). DATA SOURCE: Medical records from a multidisciplinary, outpatient, heart failure clinic, and published hospitalization and drug-use data. PATIENTS: We evaluated 170 adults with chronic heart failure who were enrolled in the clinic and for whom at least one complete blood count was recorded between January 1, 2003, and April 15, 2006. MEASUREMENTS AND MAIN RESULTS: In part 1, demographic and clinical data were extracted from electronic medical records. The overall prevalence of anemia was 47.6% or 47.1%, as based on World Health Organization or National Kidney Foundation definitions, respectively. Normocytic anemia was characterized in 75.0% of patients. In part 2, heart failure hospitalization rates and costs, drug acquisition, and drug administration were estimated by using the published literature. In a hypothetical cohort of 100 patients with heart failure and comorbid anemia, the costs associated with outpatient epoetin and intravenous iron therapy exceeded savings in hospitalization costs by $83,070. Results of 1-way sensitivity analyses generally confirmed robustness of the model. CONCLUSION: Anemia is a common comorbidity in patients with chronic heart failure treated in the outpatient clinic. Although the current evidence is insufficient to support the use of epoetin in this population, initial findings indicate that epoetin and intravenous iron therapy may be associated with positive clinical outcomes. From a pharmacoeconomic standpoint, however, a reduction in the cost of heart failure-related hospitalization does not offset the cost of epoetin and intravenous iron therapy.

Evaluation of treatment with direct thrombin inhibitors in patients with heparin-induced thrombocytopenia.

STUDY OBJECTIVE: To evaluate the efficacy, safety, and associated costs of anticoagulation with argatroban, bivalirudin, and lepirudin for managing patients with heparin-induced thrombocytopenia (HIT) or presumed HIT. DESIGN: Retrospective medical record review. SETTING: University-affiliated teaching hospital. PATIENTS: Forty-two patients who were hospitalized between January 1 and December 31, 2004, and who were treated with bivalirudin, argatroban, or lepirudin for at least 24 hours. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the time to reach the desired goal for activated partial thromboplastin time (aPTT). Secondary outcomes were the number of aPTT measurements within the therapeutic range, costs, treatment duration, clinical outcomes, and adverse events. Of the 42 patients who met the inclusion criteria, 24 received bivalirudin, 13 received argatroban, and 5 received lepirudin. Patients receiving bivalirudin who reached therapeutic aPTTs attained them sooner than those receiving either argatroban or lepirudin (8.5 vs 14 and 24 hrs, respectively, p=0.124). Average percentage of therapeutic aPTTs/patient was greatest in the argatroban group (62%), followed by the bivalirudin (57%) and lepirudin (29%) groups (p=0.062). Average drug cost/day/patient was greater in the lepirudin group than the other groups, whereas average laboratory costs were similar among groups. Treatment duration was longer with argatroban than with bivalirudin or lepirudin. Bleeding rates were similar in the argatroban and bivalirudin groups, but higher than in the lepirudin group. A composite of clinical outcomes (deep vein thrombosis, nonfatal myocardial infarction, nonfatal stroke, limb amputation, and all-cause mortality) were similar among the three groups. CONCLUSION: All three drugs were effective as anticoagulants for patients with HIT or presumed HIT. Based on average use and average wholesale price, bivalirudin cost less per day than the other two agents. Although not yet approved by the United States Food and Drug Administration for management of HIT, bivalirudin appears to be a viable treatment alternative for anticoagulation therapy.

Impact of Norepinephrine Shortage on Outcomes in Patients with Septic Shock.

PURPOSE: With the previous norepinephrine shortage, alternative agents were required to treat patients with septic shock. This retrospective study evaluated whether the shortage of norepinephrine had an adverse effect on patients admitted to the intensive care unit with a diagnosis of severe sepsis or septic shock. METHODS: This was a retrospective chart review, which compared patients who received norepinephrine versus those who did not. Eligible patients were those ≥ 18 years old who were admitted to an intensive care unit with a diagnosis of sepsis and were initiated on a vasopressor to maintain hemodynamic stability. The specific primary endpoint was whether using norepinephrine versus other vasopressors had an effect on ICU length of stay. Secondary outcomes included mortality, blood pressure, mean arterial pressure, development of renal insufficiency, and vasopressor requirements. RESULTS: There were 288 patients screened and 214 patients who met the inclusion criteria (norepinephrine group=106 and nonnorepinephrine group=108). After accounting for potential differences in disease severity (APACHE II score), age, weight and gender, there was no difference in ICU length of stay (p=0.4); however, the odds of survival were 5.9 (95% CI: 3.1 to 11.1) times higher for those in the non-norepinephrine group (p<0.0001). CONCLUSION: Based on this retrospective analysis, patients that did not receive norepinephrine had a similar ICU LOS but had a higher rate of survival. The norepinephrine shortage did not have an adverse effect on patient outcomes.

Pharmacy residency training measured through a standardized knowledge test.

PURPOSE: The use of a standardized knowledge test to assess postgraduate year 1 (PGY1) pharmacy residency training was evaluated. METHODS: This was a retrospective review of a prospectively administered exam. A bank of questions was developed by preceptors from each of the core rotation disciplines: general medicine (including ambulatory care and oncology), pediatrics, critical care (including transplantation), drug information, operations, practice management, and psychiatry. Board-certified pharmacy specialists at our institution were asked to submit 5-10 questions with answers that would likely be encountered by residents during rotation in their specific specialty area. The exam was administered at the beginning and the end of the resident's PGY1 year. RESULTS: A total of 49 PGY1 residents completed the examination during the first and last months of their residency training. Residents' overall scores improved 5-10% annually from baseline to completion of their residency. The mean overall exam score significantly improved from baseline after completion of a PGY1 residency at our institution for all four class years. All four residency classes demonstrated an increase from baseline scores in most core disciplines with the exception of practice management, which decreased every year of the examination. CONCLUSION: Scores on a standardized exam developed to assess the baseline knowledge of incoming PGY1 residents and the effect of one year of residency training improved in the majority of practice areas at the end of the year compared to scores at the beginning of the year.

The cardiovascular effects of eplerenone, a selective aldosterone-receptor antagonist.

BACKGROUND: The role of the renin-angiotensin-aldosterone system in the pathophysiology and treatment of hypertension and heart failure has been extensively studied. Angiotensin-converting enzyme inhibitors and angiotensin II-receptor blockers have been shown to effectively reduce blood pressure, protect the kidney, and reduce morbidity and mortality in patients with heart failure. Therefore, there is increased interest in the effects of aldosterone and the use of aldosterone-receptor antagonists in the treatment of cardiovascular disease. Eplerenone is the first selective aldosterone-receptor antagonist approved for the treatment of hypertension and left ventricular (LV) dysfunction after acute myocardial infarction (AMI). OBJECTIVE: The goal of this article was to review the pharmacologic properties, clinical efficacy, and tolerability of eplerenone in the treatment of hypertension, LV dysfunction, and proteinuria. METHODS: Relevant English-language articles were identified through searches of MEDLINE (1966-May 2003), Current Contents, and International Pharmaceutical Abstracts (1970-May 2003) using the terms hypertension, heart failure, eplerenone, aldosterone, and aldosterone antagonist. Other pertinent publications were identified from the reference lists of the identified articles. Information was also obtained from abstracts presented at national meetings and data on file with the manufacturer. RESULTS: In clinical trials, eplerenone alone and in combination with renin-angiotensin blockade significantly reduced both systolic and diastolic blood pressure compared with placebo (P < 0.05 to P < 0.001). In EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study), the addition eplerenone to optimal medical therapy reduced morbidity and mortality in patients with AMI and LV dysfunction, although the incidence of serious hyperkalemia was also significantly greater. In comparisons with spironolactone, eplerenone was associated with a lower incidence of gynecomastia and other sex hormone-related adverse effects. CONCLUSIONS: Either alone or in combination with other antihypertensive agents, eplerenone appears to be effective for the treatment of hypertension. Morbidity and mortality were reduced when eplerenone was added to standard therapy for LV dysfunction complicating AMI. The use of eplerenone for hypertension or heart failure may be limited in patients at risk for hyperkalemia.

Combination antiplatelet therapy: implications for pharmacists.

OBJECTIVES: To present two case reports of patients who received suboptimal oral antiplatelet therapy and to review recent changes in national guidelines for management of acute coronary syndromes. DATA SOURCES: Personal observation by the authors, and clinical practice guidelines and related clinical trials of the American Heart Association and the American College of Cardiology. SUMMARY: The American College of Cardiology and the American Heart Association revised the guidelines for administration of antiplatelet and anticoagulant therapy in patients with unstable angina and non-ST-segment elevation myocardial infarction in March 2002. Two cases observed by the authors illustrate the consequences of suboptimal antiplatelet therapy when a combination of two antiplatelet drugs should have been administered. CONCLUSION: Evidence from recent randomized controlled trials led to changes in the national guidelines for administration of oral antiplatelet therapy in patients with acute coronary syndromes. Pharmacists should be aware of these changes and counsel patients about appropriate administration of antiplatelet drugs.

The role of B-type natriuretic peptide in heart failure.

The use of BNP as a diagnostic and therapeutic tool in the management of heart failure is promising. Additional studies need to be done regarding the use of BNP as a diagnostic tool to clarify its intrapatient and interpatient variability, especially over time. Nesiritide is the first new intravenous agent for the treatment of acute decompensated heart failure since the introduction of milrinone. It is an effective vasodilator and enhances the effect of concomitant diuretic therapy. Nesiritide may have some benefit on long-term outcomes by prolonging survival, decreasing hospitalizations, or enhancing quality of life. Whether it can or should be used as chronic therapy in end-stage patients remains to be determined.

A retrospective evaluation of the efficacy of intravenous bumetanide and comparison of potency with furosemide.

BACKGROUND: The potency of intravenous bumetanide to furosemide using a ratio of 1:40 has been suggested; however, there are little data supporting this ratio. Recent drug shortages required the use of bumetanide in a large patient population, enabling further characterization of the efficacy of IV bumetanide. OBJECTIVE: The primary objective of this study was to estimate a dose-response effect of IV bumetanide on urine output (UOP) in all patients that received 48 hours of therapy as well as in a subgroup of patients with heart failure (HF). This subgroup was used to compare the potency of bumetanide with furosemide. A secondary safety objective described electrolyte replacement required during therapy. METHODS: This was a single-center retrospective study examining the dose-response effect of IV bumetanide in patients receiving at least 48 hours of intermittent (iIV) or continuous (cIV) dosing, measured by UOP per mg of drug received (mL/mg). The potency of IV bumetanide was compared with furosemide in a subset of patients with HF using pre-existing data. The safety of IV bumetanide was analyzed by quantifying electrolyte replacement received during the study period. RESULTS: The primary outcome was higher in the iIV group (n=93) at 1273 ± 844 mL/mg compared with the cIV group (n=16) at 749 ± 370 mL/mg (P=0.002). Among patients with HF who received furosemide (iIV n=30, cIV n=26) or bumetanide (iIV n=30, cIV n=3), a potency ratio of 41:1 was found for the iIV group and 34:1 for all patients with HF. There was no significant difference in electrolyte replacement between groups. CONCLUSIONS: A greater response was seen with intermittent bumetanide compared with continuous infusion bumetanide. This study supports the 40:1 dose equivalence ratio (furosemide:bumetanide) in patients with HF receiving at least 48 hours of intravenous intermittent bumetanide.

An academician preparation program for pharmacy residents.

OBJECTIVE: To assess the evolution and effectiveness of the Academician Preparation Program to provide knowledge and skills in teaching and evaluating to pharmacy residents, as well as generate interest in academic careers. DESIGN: Participants attended seminars and participated in additional teaching, precepting, facilitating, and evaluating activities. Residents maintained a teaching portfolio and met with a faculty mentor quarterly to review their progress toward completion of the requirements for the Academician Preparation Program certificate. ASSESSMENT: Since the program was first offered in 2005, it has expanded to 7 sites throughout the state. As of June 2012, 155 residents had completed the program and 20 (13%) had accepted full-time academic positions. Many others were serving as adjunct faculty members or preceptors. The majority of those enrolled in pharmacy residencies completed the program. CONCLUSION: An optional, organized academic preparation program was of interest to residents, fostered academic careers, and helped meet residency accreditation guidelines.

Multi-institutional study of women and underrepresented minority faculty members in academic pharmacy.

OBJECTIVES: To examine trends in the numbers of women and underrepresented minority (URM) pharmacy faculty members over the last 20 years, and determine factors influencing women faculty members' pursuit and retention of an academic pharmacy career. METHODS: Twenty-year trends in women and URM pharmacy faculty representation were examined. Women faculty members from 9 public colleges and schools of pharmacy were surveyed regarding demographics, job satisfaction, and their academic pharmacy career, and relationships between demographics and satisfaction were analyzed. RESULTS: The number of women faculty members more than doubled between 1989 and 2009 (from 20.7% to 45.5%), while the number of URM pharmacy faculty members increased only slightly over the same time period. One hundred fifteen women faculty members completed the survey instrument and indicated they were generally satisfied with their jobs. The academic rank of professor, being a nonpharmacy practice faculty member, being tenured/tenure track, and having children were associated with significantly lower satisfaction with fringe benefits. Women faculty members who were tempted to leave academia for other pharmacy sectors had significantly lower salary satisfaction and overall job satisfaction, and were more likely to indicate their expectations of academia did not match their experiences (p<0.05). CONCLUSIONS: The significant increase in the number of women pharmacy faculty members over the last 20 years may be due to the increased number of female pharmacy graduates and to women faculty members' satisfaction with their careers. Lessons learned through this multi-institutional study and review may be applicable to initiatives to improve recruitment and retention of URM pharmacy faculty members.

Aldosterone and aldosterone receptor antagonists in patients with chronic heart failure.

Aldosterone is a mineralocorticoid hormone synthesized by the adrenal glands that has several regulatory functions to help the body maintain normal volume status and electrolyte balance. Studies have shown significantly higher levels of aldosterone secretion in patients with congestive heart failure compared with normal patients. Elevated levels of aldosterone have been shown to elevate blood pressure, cause left ventricular hypertrophy, and promote cardiac fibrosis. An appreciation of the true role of aldosterone in patients with chronic heart failure did not become apparent until the publication of the Randomized Aldactone Evaluation Study. Until recently, the use of aldosterone receptor antagonists has been limited to patients with severe heart failure and patients with heart failure following myocardial infarction. The Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF) study added additional evidence to support the expanded use of aldosterone receptor antagonists in heart failure patients. The results of the EMPHASIS-HF trial showed that patients with mild-to-moderate (New York Heart Association Class II) heart failure had reductions in mortality and hospitalizations from the addition of eplerenone to optimal medical therapy. Evidence remains elusive about the exact mechanism by which aldosterone receptor antagonists improve heart failure morbidity and mortality. The benefits of aldosterone receptor antagonist use in heart failure must be weighed against the potential risk of complications, ie, hyperkalemia and, in the case of spironolactone, possible endocrine abnormalities, in particular gynecomastia. With appropriate monitoring, these risks can be minimized. We now have evidence that patients with mild-to-severe symptoms associated with systolic heart failure will benefit from the addition of an aldosterone receptor antagonist to the standard therapies of angiotensin-converting enzyme inhibitors and beta-blockers. This review will address the pharmacologic basis of aldosterone receptor antagonists in patients with heart failure and the clinical impact of this therapy.

Comparison of chronic systolic heart failure guideline adherence for two ambulatory clinics.

UNLABELLED: Guidelines have been published for management of chronic systolic heart failure to reduce patient morbidity and mortality. OBJECTIVE: A quality review of the heart failure medical therapy for a community family medicine residency program clinic and a multidisciplinary heart failure specialty clinic was performed to compare adherence to ACC/AHA heart failure guidelines, with regard to medications and in titrating to recommended target doses. METHODS: The study was a retrospective chart review and data collected included name and dose of any ACEI, beta-blocker, ARB, or other medication addressed in the guidelines. RESULTS: Specialty clinic patients had significantly lower systolic blood pressures and ejection fractions. Significantly more patients were prescribed beta-blockers in the specialty clinic population (98% vs 80%, p<0.05). Both patient populations had very low rates of reaching target beta-blocker doses (15% vs 21%, p=0.27). More patients in the family medicine clinic reached target doses of ACEI (64% vs 49%, p<0.05) and ARBs (67% vs 35%, p<0.05). CONCLUSIONS: This study revealed the vast majority of patients in either a community family medicine residency program or heart failure specialty clinic were prescribed ACEI or ARB, and beta-blockers. However, achieving target doses should continue to be an important goal for practitioners.