Gaps in optimal medical therapy for ICD patients still exist
MedWire News: Despite well-proven benefits and guideline recommendations, gaps in optimal medical therapy (OMT) use among patients receiving implantable cardioverter defibrillators (ICDs) still exist, say researchers.
Current guidelines promote the clinical optimization of patients with low left ventricular ejection fraction (LVEF) as well as cost-effective allocation of device therapy, write Amy Miller (Brigham and Women's Hospital, Boston, Massachusetts, USA) and colleagues in the Archives of Internal Medicine. However, they add, prior studies have hinted at significant care gaps among some ICD recipients.
They therefore studied data from an ICD registry of 175,757 patients who underwent first-time ICD implantation between January 2007 and June 2009. Patients younger than 18 years, and those who had an LVEF higher than 35%, died in hospital, or whose OMT status was unknown were excluded from the analysis.
The findings revealed that 45,240 (25.7%) patients were eligible for but did not receive OMT (defined as use of beta blocker and ACE inhibitor or angiotensin-receptor blocker in the absence of contraindications). A similar rate was observed when ICD placement was the primary purpose of hospitalization (24.6%) and among patients receiving ICD for primary prevention (25.6%).
The rate of OMT prescription by site ranged from 0% to 100%, with a median of 73.5%.
Patients who received OMT were significantly more likely to be younger (66.4 vs 69.2 years), have commercial insurance, and have a diagnosis of hypertension (p<0.0001) than those who did not receive OMT.
However, they were less likely to have a history of ischemic heart disease, recent heart failure hospitalization, atrioventricular node conduction abnormalities, or renal dysfunction (p<0.0001).
Median use of OMT was highest at government hospitals, at 78.5%, and lowest at private and/or community hospitals, at 73.7% (p<0.001).
Multivariate analysis revealed that factors associated with OMT use were treatment at a teaching hospital, percutaneous coronary intervention during admission, history of hypertension, and a cardiovascular indication for admission, at respective odds ratios (ORs) of 1.16, 1.11, 1.32, and 1.11.
Factors associated with the lowest odds of OMT use were coronary artery bypass graft during admission and an implanting care provider who was board-certified in surgery, at ORs of 0.66 and 0.73, respectively.
"From a broader perspective, the observed low rate of OMT use supports the need for increased focus on this aspect of care for patients receiving ICD therapy," write the authors.
"These results underscore the need for dedicated strategies, optimized quality of care and improved cost-effectiveness of care for patients with heart failure," they conclude.
In a related commentary, editorialists Gerald Pan and Robert temple (US Food and Drug Administration, Silver Spring, Maryland, USA) write: "Additional research might improve our understanding of other variables that predict use of OMT; for example we can explore geographic variation, temporal trends, and predictors of sustained medication compliance."
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By Piriya Mahendra