Underused Treatments Could Save Lives From Heart Failure

June 8, 2011 -- Close to 70,000 heart failure deaths could be prevented in the U.S. each year if more patients were on recommended therapies, new research suggests.

The study is among the first to quantify the impact, in terms of lives saved, of broader use of drug and cardiac device treatments for heart failure.

About 6 million people in the U.S. have heart failure and roughly 282,000 die of the disease each year, according to the CDC.

The condition occurs when the heart is unable to pump enough blood and oxygen to other organs. Common symptoms include shortness of breath during normal activity, water retention leading to swelling, and general fatigue and weakness.

Six heart failure therapies, including four drug and two nondrug treatments, have been proven to reduce deaths and are recommended by the American College of Cardiology and the American Heart Association for patients with reduced left-ventricle ejection fraction.

These treatments include:

• ACE inhibitors or angiotensen II receptor blockers (ARBs)
• Beta-blockers
• Aldosterone hormone-targeting diuretics known as aldosterone antagonists
• Hydralazine/isosorbide dinitrate
• Cardiac resynchronization therapy (CRT), which involves the implantation of a specialized pacemaker or a combination device that also includes a defibrillator
• Implantable cardiac defibrillator (ICD), which detects and corrects cardiac arrhythmias

Aldosterone Antagonists

Not all the treatments are appropriate for all patients, but guidelines call for them to be considered when indicated.

In their effort to explore the use of these six heart failure therapies, University of California, Los Angeles heart researcher Gregg C. Fonarow, MD, and colleagues examined clinical trials, inpatient and outpatient heart failure registries, and heart failure quality-of-life studies.

They found that out of about 2.6 million patients with reduced left-ventricular ejection fraction in the U.S., the largest number were eligible for and treated with for ACE inhibitor/ARB and beta-blocker therapy, while the smallest number were eligible for and treated with hydralazine/isosorbide dinitrate.

About 80% of eligible patients were prescribed ACE inhibitors/ARBs, and 86% were prescribed beta-blockers, but only 36% of patients eligible for aldosterone antagonists were on the drugs.

The researchers concluded that optimal use of all six therapies would save 68,000 lives a year in the U.S.

Optimal use of aldosterone antagonists alone accounted for a third of the estimated reduction in deaths, Fonarow tells WebMD.

"This is a readily available and very inexpensive drug that is widely underprescribed," he says.

New York City cardiologist Nieca Goldberg, MD, agrees that aldosterone antagonists are underused.

Goldberg directs the Women's Heart Program at the NYU Cardiac and Vascular Institute.

"One simple message to patients who are not on an aldosterone antagonist should be to ask their clinician if they should be," she says.

Nondrug Treatments Save Lives, Too

After aldosterone antagonists, optimal use of beta-blockers was associated with the greatest potential decrease in estimated annual deaths (almost 13,000), followed by ICD (around 12,000) and CRT (around 8,300).

The study appears in the June issue of the American Heart Journal.

While acknowledging that cost could be a factor in the underuse of the nondrug heart failure treatments, Fonarow and Goldberg agree that the causes of heart failure undertreatment are more complex than cost alone.

Heart failure patients are often older and sicker than other heart disease patients and they typically have other health problems and are on many medications.

Because of this, Goldberg says, a treatment that may be appropriate for one patient may not be appropriate for another.

"You have to consider the individual patient's co-morbidities and mix of medications," she says.