Heart failure (HF) affects approximately 4.7 million elderly patients in the United States and is responsible for more than 1 million hospital admissions annually, according to Robert Lee Page II, associate professor in the department of clinical pharmacy at the University of Colorado Denver.
Additionally, the associated costs are approximated at $10 billion to $38 billion annually, he noted.
Overall, researchers are seeing an upward trend in diastolic heart dysfunction, particularly in older women, whereas the more common systolic heart dysfunction has abated slightly in recent years due to advances in drug therapies, Page said.
Diastolic heart dysfunction is defined as a “pump problem,” or when the ejection fraction is less than 40 percent and the underlying problem is impaired left ventricular contractility, while systolic heart dysfunction is known as a “filling problem” that is characterized by a normal ejection fraction and the underlying problems of increased left ventricular stiffness and compliance and impaired relaxation.
A cornerstone of the management of HF in older adults should be pharmacotherapy, Page said.
“The holy trinity [in treating HF] is angiotensin-converting enzyme (ACE) inhibitors, diuretics and beta blockers. Those three need to be at the table when you are talking about someone with systolic dysfunction,” Page said.
Specifically, he said ACE inhibitors have been well-studied.
“We have the most robust data with ACE inhibitors. In all of these studies we used high doses. For the longest time we thought that that was what we needed to do to decrease mortality,” Page noted.
“If I had to push the dose of an agent, it would be the beta blocker,” he added. “We reduce mortality as we move toward higher doses of beta blockers. I can tell you that these are the same types of phenomena that we see with other beta blockers such as [AstraZeneca Plc's] Toprol XL (metoprolol succinate); the higher the dose the greater reduction in mortality.”
However, Page noted, patients on beta blockers will feel very fatigued for the “first three months” and providers are advised to encourage their patients to push through this phase. GlaxoSmithKline’s Plc’s beta blocker Coreg (carvedilol), which is also available as a generic, has “excellent outcomes,” Page said.
“Not only does it reduce systemic vascular resistance thereby improving stroke volume, and not only does it increase ejection fraction, but it has antioxidant benefits that we don’t see with some of the others,” he said.
In regard to the mixed reviews for digoxin, Page referred to studies that show some benefit in patients who have New York Heart Association class III (moderate) and class IV (severe) HF.
Drugs that should be avoided in seniors with HF, according to Page, include: class I and class II antiarrhythmics; nondihydropyridine calcium channel blockers; metformin hydrochloride and thiazolidinedione; anagrelide; cilostazol; amphetamines; clozapine; ergot alkaloids; pergolide, which has been discontinued; tricyclic antidepressants; beta-2 agonists; and cyclooxygenase 1 and 2 nonsteroidal anti-inflammatory drugs.
That there are no studies on diastolic heart dysfunction or drugs for the less common disorder in the pipeline is “sad,” he noted, adding that “in my mind, this is a public health concern.”
Consequently, consultant pharmacists are advised to make themselves heard in the management of seniors. They have the opportunity to be a “reconciler” with regard to drugs and discharge information; to be a “detective” with regard to specific drugs, doses and appropriate length for drug interactions; and to be a “negotiator” between all the providers.
“When we add you, we see a reduction in mortality. When we add you to a team, you are an intervention in and of yourself,” Page said.
–From VerusMed.com
