Optimization Of Medical Therapy In African-American Patients With Heart Failure Referred For Cardiac Resynchronization Therapy

Background: Heart failure (HF) remains a national epidemic. Optimal medical therapy (OMT) for HF includes ACE-inhibitors (ACEI), aldosterone antagonists, and beta-blockers. In African American (AA) patients, the addition of fixed dose isosorbide dinitrate and hydralazine (ISDN/H) to standard medical therapy increases survival in advanced HF (A-HeFT Investigators). Current practice guidelines support the addition of ISDN/H to standard HF medications in AA patients with symptomatic systolic dysfunction. Cardiac resynchronization therapy (CRT) should be considered only if patients remain symptomatic from HF despite OMT. We looked at the utilization of OMT in AA patients with HF referred for CRT at a single, urban teaching institution. Methods: We conducted a retrospective chart review of 216 patients referred for CRT from Nov 2004 (date of A-HeFT publication) to Jan 2007, in order to determine the utilization of OMT at the time of CRT referral. Individuals were classified by self-identified race. Results: Medication information was available in 192 patients. Of these, 48 (25%) were AA, 53 (27.6%) were Caucasian, 81 (42.2%) were Hispanic, and 10 (5.2%) were other or unidentified. Of the 48 AA patients referred for CRT, utilization of medications was as follows: 89.6% beta-blocker, 70.8% ACEI, 22.9% ARB, 62.5% aldosterone antagonist, 6.7% fixed dose ISDN/H, 0% individual components ISDN/H, and 12.5% individual components isosorbide mononitrate and hydralazine (ISMN/H). AA patients were more likely to be on aldosterone antagonists than Caucasians or Hispanics. The percent of patients on each HF drug at the time of CRT is shown in Figure 1. Conclusions: Despite current evidence-based guidelines regarding optimal medical therapy in patients with HF, less than 1 in 10 AA patients were on fixed-dose or individual components of ISDN/H at the time of referral for CRT. Potential reasons for underutilization of these medications should be explored, as studies demonstrate that adherence to practice guidelines can have a substantial impact on HF survival and readmission rates.