Medication regimen complexity in ambulatory older adults with heart failure

Michael R Cobretti,1 Robert L Page II,2 Sunny A Linnebur,2 Kimberly M Deininger,1 Amrut V Ambardekar,3 JoAnn Lindenfeld,4 Christina L Aquilante1 1Department of Pharmaceutical Sciences, 2Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, 3Division of Cardiology, School of Medicine, University of Colorado, Aurora, CO, 4Advanced Heart Failure and Cardiac Transplant Program, Vanderbilt Heart and Vascular Institute, Nashville, TN, USA Purpose: Heart failure prevalence is increasing in older adults, and polypharmacy is a major problem in this population. We compared medication regimen complexity using the validated patient-level Medication Regimen Complexity Index (pMRCI) tool in “young-old” (60–74 years) versus “old-old” (75–89 years) patients with heart failure. We also compared pMRCI between patients with ischemic cardiomyopathy (ISCM) versus nonischemic cardiomyopathy (NISCM).Patients and methods: Medication lists were retrospectively abstracted from the electronic medical records of ambulatory patients aged 60–89 years with heart failure. Medications were categorized into three types – heart failure prescription medications, other prescription medications, and over-the-counter (OTC) medications – and scored using the pMRCI tool.Results: The study evaluated 145 patients (n=80 young-old, n=65 old-old, n=85 ISCM, n=60 NISCM, mean age 73±7 years, 64% men, 81% Caucasian). Mean total pMRCI scores (32.1±14.4, range 3–84) and total medication counts (13.3±4.8, range 2–30) were high for the entire cohort, of which 72% of patients were taking eleven or more total medications. Total and subtype pMRCI scores and medication counts did not differ significantly between the young-old and old-old groups, with the exception of OTC medication pMRCI score (6.2±4 young-old versus 7.8±5.8 old-old, P=0.04). With regard to heart failure etiology, total pMRCI scores and medication counts were significantly higher in patients with ISCM versus NISCM (pMRCI score 34.5±15.2 versus 28.8±12.7, P=0.009; medication count 14.1±4.9 versus 12.2±4.5, P=0.008), which was largely driven by other prescription medications.Conclusion: Medication regimen complexity is high in older adults with heart failure, and differs based on heart failure etiology. Additional work is needed to address polypharmacy and to determine if medication regimen complexity influences adherence and clinical outcomes in this population. Keywords: medication complexity, heart failure, elderly, geriatric, age

Identifying ambulatory advanced heart failure patients at high risk for death, LVAD or transplant at 1-year: How did the revival eligibility criteria perform?

Purpose: Identifying ambulatory advanced heart failurepatients who are at high risk for receiving an LVAD, a transplant or death is important in appropriately guiding clinical care, and in selecting patients for clinical trials. We evaluated the REVIVAL Registry inclusion criteria to determine their ability to identify patients who experienced any of these events within 1 year of enrollment. Methods: REVIVAL is a 400 patient, 21 center registry of patients with ambulatory advanced heart failure. Exclusion criteriaapproximated thoseof VAD clinical trials. Patients were eligible for inclusion if they met any of eight high riskcharacteristics (first 8 rows of Table) or if they had ≥ 2 HF hospitalizations in the prior year. As clinically indicated testing was utilized for inclusion, data were not available for all subjects for each criterion. Sensitivity, specificity, positive and negative predictive values were determined foreach inclusion criterion and for selected combinations Results: At 12 months, 359 evaluable subjects experienced 46 LVADs, 20 transplants and 29 deaths for a total of 95 events (26%). Competing outcome curves are shown in theFigure and test performance in the Table Conclusion: Theuse of multiple inclusion criteria applied to only clinically available information allowed identification of a high risksample of ambulatory advanced heart failure patients with a 26% event rate at 1 year. These findings can inform theselection of patients for future clinical trials in ambulatoryadvanced heart failure (Figure presented)

Experiences of a community pharmacy service to support adherence and self-management in chronic heart failure

Background: Heart failure (HF) is common, disabling and deadly. Patients with HF often have poor self-care and medicines non-adherence, which contributes to poor outcomes. Community pharmacy based cognitive services have the potential to help, but we do not know how patients view community-pharmacist-led services for patients with HF. Objective: We aimed to explore and portray in detail, the perspectives of patients receiving, and pharmacists delivering an enhanced, pay for performance community pharmacy HF service. Setting: Community pharmacies and community-based patients in Greater Glasgow and Clyde, Scotland. Methods Focus groups with pharmacists and semi-structured interviews with individual patients by telephone. Cross sectional thematic analysis of qualitative data used Normalization Process Theory to understand and describe patient's reports. Main outcome measure: Experiences of receiving and delivering an enhanced HF service. Results: Pharmacists voiced their confidence in delivering the service and highlighted valued aspects including the structured consultation and repeated contacts with patients enabling the opportunity to improve self care and medicines adherence. Discussing co-morbidities other than HF was difficult and persuading patients to modify behaviour was challenging. Patients were comfortable discussing symptoms and medicines with pharmacists; they identified pharmacists as fulfilling roles that were needed but not currently addressed. Patients reported the service helped them to enact HF medicines and HF self care management strategies. Conclusion: Both patients receiving and pharmacists delivering a cognitive HF service felt that it addressed a shortfall in current care. There may be a clearly defined role for pharmacists in supporting patients to address the burden of understanding and managing their condition and treatment, leading to better self management and medicines adherence. This study may inform the development of strategies or policies to improve the process of care for patients with HF and has implications for the development of other extended role services

A computational model that predicts reverse growth in response to mechanical unloading

International audienceVentricular growth is widely considered to be an important feature in the adverse progression of heart diseases, whereas reverse ventricular growth (or reverse remodeling) is often considered to be a favorable response to clinical intervention. In recent years, a number of theoretical models have been proposed to model the process of ventricular growth while little has been done to model its reverse. Based on the framework of volumetric strain-driven finite growth with a homeostatic equilibrium range for the elastic myofiber stretch, we propose here a reversible growth model capable of describing both ventricular growth and its reversal. We used this model to construct a semi-analytical solution based on an idealized cylindrical tube model, as well as numerical solutions based on a truncated ellipsoidal model and a human left ventricular model that was reconstructed from magnetic resonance images. We show that our model is able to predict key features in the end-diastolic pressure–volume relationship that were observed experimentally and clinically during ventricular growth and reverse growth. We also show that the residual stress fields generated as a result of differential growth in the cylindrical tube model are similar to those in other nonidentical models utilizing the same geometry

Management of Ventricular Arrhythmias in Patients with Mechanical Ventricular Support Devices

The use of mechanical ventricular support devices in the management of patients with advanced heart failure continues to increase. These devices have been shown to prolong life as a destination therapy and to increase survival when used as a bridge to transplantation. However, they are associated with a high rate of complications, including bleeding, infection, device malfunction, and ventricular arrhythmias (VAs). The mechanical support provided by the device typically allows for VAs to be well tolerated in the acute setting, though there are numerous long-term complications related to VAs such as ventricular remodeling, right ventricular failure in patients with left ventricular assist devices, and possibly increased mortality. Controversy exists as to the appropriate role of implantable cardioverter defibrillators in these patients. This review will focus on the management options available for patients with mechanical ventricular support devices and VAs