Severe Heart Failure Undertreated: Study

Doctors need to devote more time, effort managing these cases, experts say

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By Ed Edelson
HealthDay Reporter

TUESDAY, Sept. 13, 2005 (HealthDay News) -- Heart failure patients who need drug therapy the most after release from the hospital are the least likely to get it, a Canadian study finds.

And a likely explanation is that doctors may not be spending the time needed to care for these higher-risk patients, said lead researcher Dr. Douglas S. Lee, a research fellow at the University of Toronto.

"Higher-risk patients are more complicated to treat and probably require a lot more time and a lot more effort. That may be one of the primary reasons," said Lee, whose team published its findings in the Sept. 14 Journal of the American Medical Association.

In medicine as in business, time is money, and according to Lee, "doctors are paid the same amount for treating high-risk and low-risk patients." He and another expert agreed that this pattern occurs in the United States, as well.

Because no other treatment options exist, proper drug therapy is vital for people with heart failure, in which the heart progressively loses its ability to pump blood. Other heart problems can be treated in a number of other ways, including bypass surgery and angioplasty to open blocked arteries, Lee pointed out.

Yet in the study of more than 1,400 Ontario residents hospitalized for heart failure, those judged to be at highest risk of dying within a year after release were significantly less likely to be prescribed front-line medications for the condition, the study found.

The risk assessment was based on a number of factors, including age (older people are at higher risk), kidney function, and the presence of other medical problems. Persons in the highest risk category had a 50 percent chance of dying within a year, Lee said.

Yet only 60 percent of them were prescribed ACE inhibitor drugs to treat their condition, compared to 73 percent of people in the middle-risk group and 81 percent of those in the low-risk group. Similarly, 24 percent of the high-risk patients were prescribed beta blocker medicines, compared to 33 percent of those classified as medium risk and 40 percent of those in the low-risk group.

The neglect continued outside the hospital. Within 90 days of discharge, 61 percent of the high-risk patients were prescribed ACE inhibitors, while 76 percent of the middle-risk group and 83 percent of the low-risk group got the prescriptions. Post-hospital numbers were similar for the other heart failure drugs, as well, the study found.

The Canadian findings "would likely also be true in the United States," said Lee, who is also a research associate with the Massachusetts-based Framingham Heart Study.

A study reported last year found consistent underuse of medications for heart failure patients. The new report adds another dimension to that finding, said Dr. Frederick Masoudi, associate professor of medicine at the Denver Health Medical Center, a leader of the earlier study.

"It shows not only that medications are underused but also a systematic failure of physicians to calibrate their treatment to the underlying risk of patients," Masoudi said. "The complexity of some of these patients does create additional challenges for the physicians, but the complexity shows the need for understanding the risk of individual patients and calibrating the treatment that will benefit them the most."

Another report in the same issue of the journal confirmed the value of using drug-coated stents, instead of bare metal tubes, to keep blood vessels open after the artery-clearing procedure called angioplasty.

Nine months after implantation, only 13.7 percent of the arteries implanted with these drug-eluting stents closed again, compared to 31.9 percent of those that got bare-metal stents, concluded a study of more than 1,100 patients by physicians at Columbia University Medical Center in New York City.

More information

There's more on heart failure at the American Heart Association.

SOURCES: Douglas S. Lee, M.D., Ph.D., research fellow, University of Toronto; Frederick Masoudi, M.D., associate professor of medicine, Denver Health Medical Center; Sept. 14, 2005, Journal of the American Medical Association

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