Jamie Han1, Francisco Chung1, Quyen L Nguyen1, Freny Vaghaiwalla Mody1,2,3, Cynthia A Jackevicius1,4,5,6. 1. Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California. 2. Division of Cardiology, University of California, Los Angeles, Los Angeles, California. 3. David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California. 4. Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, California. 5. Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada. 6. Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
Abstract
STUDY OBJECTIVE: Despite evidence that supports the use of sacubitril/valsartan - the first angiotensin II receptor blocker-neprilysin inhibitor - for mortality reduction in patients with heart failure (HF), it remains underprescribed. The objective of this study was to evaluate eligibility for initiation of sacubitril/valsartan treatment in patients with HF within the largest Veterans Administration healthcare system in the United States. DESIGN: Cross-sectional study. SETTING: Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS). PATIENTS: A total of 2985 patients with a HF diagnosis who were alive as of November 1, 2017. MEASUREMENTS AND MAIN RESULTS: Eligibility for sacubitril/valsartan initiation was based on inclusion and exclusion criteria from the Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor with Angiotensin-Converting-Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial and the VA Criteria for Use. The proportion of eligible patients was estimated, and characteristics of eligible patients were compared with those in the PARADIGM-HF trial. Of the 2985 patients with HF who were alive as of November 1, 2017, 965 (32.3%) had HF with reduced ejection fraction (HFrEF). Of these patients with HFrEF, 263 (27.3%) fulfilled eligibility criteria and were considered candidates for sacubitril/valsartan initiation. Of the 702 patients who did not fulfil eligibility criteria, the most common reasons were New York Heart Association functional class I (35.3%) and B-type natriuretic peptide level of 100 pg/ml or lower (22.2%). Compared with patients in the PARADIGM-HF trial, VAGLAHS patients were older (70.4 vs 63.8 yrs) and more likely to be male (98.5% vs 79.0%), and a higher proportion had New York Heart Association functional class III symptoms (35.4% vs 23.1%). Of the 965 patients with HFrEF, 34 (3.5%) had an active sacubitril/valsartan prescription as of November 1, 2017, of whom 27 (79.4%) did not meet criteria. CONCLUSION: Whereas 27% of patients with HFrEF were eligible to initiate sacubitril/valsartan, only 3.5% of these patients were prescribed the medication. Although sacubitril/valsartan reduced morbidity and mortality in clinical trials, it remains underused within this VA healthcare system. This analysis provides important insights into the VA and other healthcare systems regarding the opportunity for optimizing guideline-directed HF therapy.
STUDY OBJECTIVE: Despite evidence that supports the use of sacubitril/valsartan - the first angiotensin II receptor blocker-neprilysin inhibitor - for mortality reduction in patients with heart failure (HF), it remains underprescribed. The objective of this study was to evaluate eligibility for initiation of sacubitril/valsartan treatment in patients with HF within the largest Veterans Administration healthcare system in the United States. DESIGN: Cross-sectional study. SETTING: Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS). PATIENTS: A total of 2985 patients with a HF diagnosis who were alive as of November 1, 2017. MEASUREMENTS AND MAIN RESULTS: Eligibility for sacubitril/valsartan initiation was based on inclusion and exclusion criteria from the Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor with Angiotensin-Converting-Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial and the VA Criteria for Use. The proportion of eligible patients was estimated, and characteristics of eligible patients were compared with those in the PARADIGM-HF trial. Of the 2985 patients with HF who were alive as of November 1, 2017, 965 (32.3%) had HF with reduced ejection fraction (HFrEF). Of these patients with HFrEF, 263 (27.3%) fulfilled eligibility criteria and were considered candidates for sacubitril/valsartan initiation. Of the 702 patients who did not fulfil eligibility criteria, the most common reasons were New York Heart Association functional class I (35.3%) and B-type natriuretic peptide level of 100 pg/ml or lower (22.2%). Compared with patients in the PARADIGM-HF trial, VAGLAHS patients were older (70.4 vs 63.8 yrs) and more likely to be male (98.5% vs 79.0%), and a higher proportion had New York Heart Association functional class III symptoms (35.4% vs 23.1%). Of the 965 patients with HFrEF, 34 (3.5%) had an active sacubitril/valsartan prescription as of November 1, 2017, of whom 27 (79.4%) did not meet criteria. CONCLUSION: Whereas 27% of patients with HFrEF were eligible to initiate sacubitril/valsartan, only 3.5% of these patients were prescribed the medication. Although sacubitril/valsartan reduced morbidity and mortality in clinical trials, it remains underused within this VA healthcare system. This analysis provides important insights into the VA and other healthcare systems regarding the opportunity for optimizing guideline-directed HF therapy.
Authors: April F Mohanty; Emily B Levitan; Jordan B King; John A Dodson; Orly Vardeny; James Cook; Jennifer S Herrick; Tao He; Olga V Patterson; Patrick R Alba; Patricia A Russo; Engels N Obi; Michelle E Choi; James C Fang; Adam P Bress Journal: J Am Heart Assoc Date: 2021-10-06 Impact factor: 5.501