Matters of the heart.

Life-saving drugs for cardiac disease are still underused

THE USE OF A FOUR-DRUG REGIMEN COULD IMPROVE AND possibly save the lives of tens of thousands of patients who suffer from a form of congestive heart failure, recent research reveals. Yet, up to 60 percent of heart failure patients do not receive the full complement of recommended drugs, a panel of more than 150 leading experts has concluded. In nursing homes, undertreatment is even more common.

In a consensus report published in February in the American Journal of Cardiology, doctors recommend most patients be treated with ACE inhibitors and beta-blockers in combination with commonly used digitalis and diuretics. According to the report, only about 40 percent of patients receive ACE inhibitors and just 5 percent are treated with beta-blockers.

"Most primary care physicians need to become more knowledgeable, more experienced in using some of these new drugs," says Jay N. Cohn, MD, co-chair of the steering committee that wrote the report, and professor of medicine at the University of Minnesota Medical School.

The report was based on an 18-month review of available data on the treatment of heart failure, including numerous clinical studies indicating that the use of ACE inhibitors and beta-blockers in combination with digitalis and diuretics can dramatically improve outcomes.

Heart failure is primarily "an illness of the elderly," notes JoAnn Lindenfeld, MD, director of the cardiology transplant program at the University of Colorado. Cases are on the rise, in part because new treatments for heart attack patients are saving lives but leaving survivors with damaged hearts.

The report addressed the pharmacological treatment of patients with chronic systolic heart failure, heart failure caused when a weakened heart muscle does not pump blood forcefully enough. Diastolic heart failure, which occurs when the heart is unable to fill up during the relaxation phase, is caused by stiffening of the heart muscle.

There have been no large clinical trials on patients who suffer exclusively from diastolic heart failure. It's likely the treatment recommendations will overlap, says Lindenfeld.

To date, researchers have focused on systolic heart failure, believing that the majority of heart failure patients--up to 70 percent--suffer from this form of the disease. Now there is mounting evidence to suggest that the incidence of diastolic heart failure increases with age. Patients can suffer from both forms of the disease.

The use of the ACE inhibitors was first recommended in the late 1980s, says William T. Abraham, MD, director of heart failure and cardiac transplantation at the University of Cincinnati College of Medicine and a member of the steering committee. The beta blocker carvedilol (Coreg) was approved in May 1997 for heart failure. Two other beta-blockers--metotrolol (Toprol XL) and bisoprolol (Zebeta and Ziac)--have been studied and proven effective but have not been approved specifically for heart failure, according to Abraham.

In part, ACE inhibitors and beta-blockers may be underprescribed because the use of new drug therapies often lags research, notes Lindenfeld. Doctors also may shun ACE inhibitors and beta-blockers for fear of side effects that can occur if the drugs are not administered properly.

"There is the perception, and it's unfounded, that these newer drugs are difficult to use," says Abraham. That's particularly true with beta-blockers, which relax the heart and cause it to beat more slowly. When initially administered to heart failure patients, the drugs may exacerbate such symptoms as low blood pressure, fluid retention, and fatigue. To avoid such problems, patients should be started on the drugs slowly at first and carefully monitored until the correct and most effective dosage can be determined.

In nursing facilities, another deterrent is at work: the cost limits on drugs prescribed by Medicare's new prospective payment system for SNFs. Though the obstacle is not easy to overcome, the development of formularies and clinical pathways can help ensure residents receive optimal medication therapies.

All patients with systolic heart failure should receive both ACE inhibitors and beta-blockers, unless they have demonstrated an intolerance for the drugs, conclude researchers.

Katherine J. Paul, a freelance writer in Hiram, Ohio, is a frequent contributor to Contemporary Long Term Care.

STAT

Pharmaceutical news

Double duty. The Parkinson's disease drug Requip may help other patients. A study in the March issue of the journal Movement Disorders shows the drug can be effective in treating the Restless Legs Syndrome, a disorder characterized by unusual sensations that typically occur deep within the legs.

Fighting diabetes. An FDA panel recommended in April that Avandia, a new diabetes drug, be approved. SmithKline Beecham makes the drug, which works in the same way as Rexulin but appears to have fewer serious side effects affecting liver function.