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 Table of Contents  
Year : 2022  |  Volume : 19  |  Issue : 2  |  Page : 151-156

Prescription patterns of evidence-based heart failure medications in a Tertiary Hospital in North-Western Nigeria—A retrospective study

1 Department of Medicine, Bayero University; Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Medicine, Bayero University; Department of Medicine, Murtala Mohammed Specialist Hospital, Kano, Nigeria

Date of Submission01-Jun-2022
Date of Decision10-Sep-2022
Date of Acceptance03-Oct-2022
Date of Web Publication23-Nov-2022

Correspondence Address:
Hadiza Saidu
Department of Medicine, Bayero University/Murtala Muhammed Specialist Hospital, Kano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njbcs.njbcs_34_22

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Context: Several large clinical trials on the use of medical therapy in the management of heart failure have shown angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), beta blockers (BBs), and mineralocorticoid receptor antagonists (MRAs) to be of proven benefit and are recommended by guidelines. Aim: The aim of this study is to describe the trend of prescription and dosing of evidence-based medications used for chronic heart failure (CHF) in our population. Settings and Design: This is a retrospective study on the pattern of prescription of evidence-based heart failure medications on 200 consecutive patients with CHF who attended the cardiology clinic or were admitted into the Medical wards from January 2020 to December 2020 at Murtala Muhammed Specialist Hospital, Kano, North-Western Nigeria. The data was obtained from patients' records. Statistical Analytics Used: Data obtained were analyzed using Statistical Package for Social Sciences (SPSS) version 23 software. (SPSS Inc. Illinois, USA). Results: ACE inhibitors or ARBs were prescribed in 89 (44.5%), BBs in 76 (38%), and MRAs, in 192 (96%). None of the patients were prescribed angiotensin receptor-neprilysin inhibitors (ARNi) or sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors). Conclusion: Evidence-based heart failure medications are underutilized in patients with CHF in our population. Improved uptake and up-titration are needed for better patients' outcomes.

Keywords: Evidence-based, heart failure medications, prescriptions

How to cite this article:
Nalado AM, Saidu H. Prescription patterns of evidence-based heart failure medications in a Tertiary Hospital in North-Western Nigeria—A retrospective study. Niger J Basic Clin Sci 2022;19:151-6

How to cite this URL:
Nalado AM, Saidu H. Prescription patterns of evidence-based heart failure medications in a Tertiary Hospital in North-Western Nigeria—A retrospective study. Niger J Basic Clin Sci [serial online] 2022 [cited 2023 Mar 31];19:151-6. Available from: https://www.njbcs.net/text.asp?2022/19/2/151/361892

  Introduction Top

Heart failure is a common cardiovascular condition with increasing incidence and prevalence and is associated with significant morbidity and mortality. It is a clinical syndrome caused by various cardiac conditions that impair the ability of the ventricles to fill with or eject blood. The initiation and up-titration of evidence-based therapies, once the diagnosis is made, has been shown to reduce symptoms, minimize the number of hospitalizations, and prevention of premature death.[1],[2] Current evidence-based guidelines recommend that patients should be treated to trial-directed doses for angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), or angiotensin receptor neprilysin inhibitor (ARNi), (sacubitril/valsartan), where ACE inhibitors are not tolerated; beta-adrenergic blockers (BBs) and mineralocorticoid receptor antagonists (MRAs), as first-line therapy in the management of patients with heart failure with reduced ejection fraction (HFrEF), to reduce heart failure hospitalization and death.[3] Diuretics are the only agents that can adequately control fluid retention and are thus recommended in HFrEF patients with fluid retention to improve symptoms.[4] SGLT2 inhibitors, dapagliflozin, and empagliflozin are also recommended for patients with HFrEF to reduce the risk of HF hospitalization and death.[5],[6],[7] Although clinical guidelines provide a valuable tool to support physicians in managing HF patients, ensuring optimal use of evidence-based medications in routine clinical practice is a major concern and challenge worldwide.[8],[9],[10] Under treatment, doses that are less than 50% of the guideline-recommended dose for ACE inhibitors or ARBs and BBs are associated with poorer prognosis.[11],[12],[13],[14] Morbidity and mortality from heart failure have remained high, although variable, which could be due to differences in the severity of the disease and appropriate use of evidence-based treatment.

Several studies that assessed treatment uptake in patients with heart failure suggest that many patients do not receive the guideline-recommended therapies or at low doses with minimal attempts at up-titration.[15],[16] Hospital-based studies, especially in specialized centers, however, show higher uptake of the use of these medications than population-based studies.[17],[18],[19],[20],[21] Studies have shown the optimal treatment to be more challenging in the elderly, women, and patients with multiple comorbidities and contraindications for treatments.[19],[21]

There is a paucity of data on the prescription pattern and dosing of evidence-based heart failure therapy in Northern Nigeria. This study focuses on these deficits to extend the present knowledge in treating patients with chronic heart failure (CHF). The objectives of the study are, therefore, to develop baseline data on drug prescribing patterns and dosing of evidence-based heart failure medications, evaluate the prevalent prescribing practices in accordance with the guidelines, and study the use of monotherapy and combination drug therapy in these patients.

  Materials and Methods Top

Data from 200 consecutive patients with a diagnosis of CHF who attended the cardiac clinic, department of Medicine from January 2020 to December 2020, were collected retrospectively from the Medical Records Department of Murtala Muhammed Specialist Hospital. All patients diagnosed with CHF with reduced or preserved ejection fraction based on Framingham criteria and echocardiographic assessment were included.[8],[22]

Patients with CHF were categorized as having heart failure with preserved ejection fraction (EF >50%), HFrEF (EF <40%), heart failure with mid-range ejection fraction (EF 40-49%), based on the European Society of Cardiology guidelines.[8] Inclusion criteria were: 1. age >18 years; 2. patients attending the cardiac clinic with a diagnosis of CHF; 3. CHF patients were admitted with acute decompensation. Exclusion criteria were: 1. acute de novo heart failure; 2. asymptomatic patients with echocardiographic evidence of LV dysfunction.

Demographic and clinical variables noted included age, gender, underlying aetiology of heart failure, associated comorbidities, and maximal dosage of heart failure medications used by the patient. Medications were identified by therapeutic class, including ACE inhibitors, ARBs, BBs, MRAs, and others (loop diuretics, antiplatelets, anticoagulants, digoxin, and inotropic agents). Laboratory investigations, including blood glucose, serum electrolytes, renal function tests, electrocardiographic and echocardiographic parameters, were reviewed from the record of the patients.

Ethical approval was obtained from the State Health Research Ethics Committee before the commencement of the study (SHREC/2022/3363; March 10, 2022).

Data obtained were analyzed using Statistical Package for Social Sciences version 23 software. Continuous variables were presented as mean and standard deviation. Qualitative variables were expressed as proportions and percentages. The tabular presentation was made for necessary variables.

  Results Top

Two hundred consecutive patients with a diagnosis of CHF were included in the study. There were 69 (34.5%) males and 131 (65.5%) females (ratio of 1:1.9), and their ages ranged from 15 to 90 years (mean 49.78 ± 12.28) years. The baseline characteristics of the patients are presented in [Table 1].
Table 1: Baseline characteristics of patients with chronic heart failure (n=200)

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The most common causes of heart failure identified were hypertensive heart disease 88 (44.1%), peripartum cardiomyopathy (PPCM) 78 (38.8%) and dilated cardiomyopathy 12 (6.2%), and rheumatic heart disease 10 (5.0%). Other causes of CHF included IHD, cor pulmonale, and pericardial diseases. [Figure 1] shows the distribution of the causes of heart failure. All patients were prescribed at least one class of guideline-recommended medical therapies. ACE inhibitors or ARBs were prescribed to 89 (44.5%), BBs to 76 (38%), and MRAs to192 (96%). Loop and thiazide diuretics, digoxin, antiplatelets and anticoagulants were prescribed to 157 (78.5%), 148 (74%), 136 (68%) and 18 (9%) respectively. The pattern of prescription of the individual drug class is presented in [Figure 2]. The most prescribed ACE inhibitors were lisinopril and ramipril, while losartan and telmisartan were the most prescribed ARBs [Table 2]. Recommended doses for ACE inhibitors/ARBs were only reached in 11 (12%), while 66 (77%) were prescribed less than 50% of the guideline-recommended doses. Carvedilol and Metoprolol were the most prescribed BBs, with 65 (85%) of the patients prescribed less than 50% of the guideline-recommended dose, and only 7 (8.5%) achieved the guideline-recommended dose. Spironolactone was the only prescribed MRA in 188 (94%), and all the patients were prescribed up to 50% of the guideline-recommended dose. None of the patients were on angiotensin receptor-neprilysin inhibitors (ARNi) or sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors).
Figure 1: Causes of CHF in the study population. CHF: chronic heart failure; HHD: hypertensive heart disease; PPCM: peripartum heart failure; DCM: dilated cardiomyopathy; RHD: rheumatic heart disease; IHD: ischemic heart disease; CP: cor pulmonale; PD: pericardial diseases

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Figure 2: Distribution pattern of the individual drug classes. ACEIs: angiotensin converting enzyme inhibitors; ARBs: angiotensin receptor blockers; BBs: beta blockers; MRAs: mineralocorticoid receptor blockers

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Table 2: Individual drugs used in patients with chronic heart failure (n=200)

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The individual drugs and different drugs combination used in patients with CHF are presented in [Table 2] and [Table 3].
Table 3: Different drugs combination used in patients with chronic heart failure (n=200)

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  Discussion Top

This study evaluated the pattern of use of different evidence-based therapy in patients with CHF. The aims of CHF treatment are to reduce symptoms, the number of hospitalizations, and the improvement of survival. Treatment is thus focused on minimizing the detrimental effects of neurohormonal compensatory mechanisms.

Diuretics remain the first line of treatment for volume overload. They reduce pulmonary edema and venous congestion, providing rapid relief of symptoms.[23] Diuretics were administered in 78.5% of our patients, and the most prescribed was Furosemide in 65.5%. 9% received torasemide and 3% hydrochlorothiazide. Diuretics administration was high as in previous studies, as they are needed to reduce pulmonary and venous congestion in most patients.[17],[18],[19],[20],[21] ACE inhibitors/ARBs, BBs, and MRAs have been documented to improve the clinical status and survival of patients with CHF.[2],[3],[4] ACE inhibitors have effects on both preload and afterload. In addition, they cause a rise in bradykinin levels which results in the release of nitric oxide and other endogenous vasodilators.[21] Various prospective randomized placebo-controlled trials have proven the effects of ACE inhibition to prolong survival and support their use as first-line agents in the management of CHF.[13],[14],[24] The ARBs act at the angiotensin II receptor level blocking the effects of angiotensin II and can be used as an alternative to ACE inhibitors were not tolerated.[25],[26],[27],[28] In addition, they do not cause cough, as seen with ACE inhibitors. In the present study, 44.5% of our patients were prescribed ACE inhibitors or ARBs. This may be attributed to poor awareness of the managing physicians or fear of worsening renal function. The finding is lower than what was previously reported by Conrad et al. in the UK and from the ASIAN HF registry, of 73% and 77%, respectively.[20],[29] In the ASIAN HF registry involving 46 centers in 11 countries, the uptake of ACE inhibitors was highest in South Korea and lowest in China, Thailand, and Japan.[29] Among the US patients, prescription rates improved from 42% for ACE inhibitors from the first to 73% in the second year. BBs prescription also improved from 22% in the first year to 70% in the second year.[26] In this study, only 38% of the patients were prescribed BBs, 33% of which received carvedilol, and 5% received metoprolol. In a previous study, among patients with PPCM, Karaye et al. reported a lower prescription rate for both ACE inhibitors and BBs of 34.8% and 23.4%, respectively.[30] However, other studies among patients with PPCM had a very high uptake of evidence-based medications.[31],[32],[33] Moulig et al.[33] in Germany reported as high as 94% uptake for ACE inhibitors and ARBs and 97% for BBs. This high uptake of evidence-based medications may explain the low mortality and high cardiac recovery in these PPCM patients. The low prescription of BBs may be due to fear of worsening heart failure or the patients' failure to achieve euvolemia to allow the introduction of this medication.

The beneficial role of BBs in the treatment of heart failure is well established. Randomized placebo-controlled studies show that carvedilol, metoprolol CR/XR, and bisoprolol reduce morbidity and mortality in minimally, moderately, or severely symptomatic patients with HF.[33],[34],[35],[36] The BBs were used in addition to ACE inhibitors in all these trials. The incremental mortality benefit observed with these BBs is greater than those observed with ACE inhibitors alone or with other classes of agents.

Spironolactone is a competitive antagonist of aldosterone and shows beneficial effects in patients already treated with ACE inhibitors.[37] In our study, spironolactone was prescribed in up to 94% of the patients, all reaching up to 50%, the recommended targeted dose. This is similar to the previous report by Karaye et al., also from North-western Nigeria.[38] However, a number of previous studies reported lower uptake of MRAs, the least 3% within the first year, reported by Conrad et al., in the USA.[15],[16],[17],[18],[19],[20]

The underuse of the disease-modifying drugs such as BBs, ACE inhibitors, or ARBs observed in this study is consistent with the findings of previous reports.[15],[16],[17],[18],[19] Similarly, the widespread under-dosing of ACE inhibitors or ARBs and BBs found is consistent with the pan-European study and the Asian Heart Failure Registry (ASIAN-HF), where full doses of guideline-directed medical therapy were achieved in 22% and 28% for patients given ACE inhibitors and in 12% and 25% for BBs.[10],[29] Although we did not determine the factors that influence the prescription and up-titration of the medications, the ASIAN-HF observed that patients in high-income countries such as Singapore, Hong Kong, Korea, and Japan more likely to be prescribed dual first-line medications compared with lower income countries, consistent with PURE and INTER-CHF. However, socioeconomic status did not affect the up-titration of guide-directed medical therapy, and patients in Japan were prescribed the lowest doses of BBs. In contrast, those in lower-income regions, such as India and Thailand, were prescribed the highest doses.[29],[37],[39],[40] Other factors that may influence the underuse of evidence-based medications may include poor awareness among physicians, late presentation and severity of CHF, delivery and quality of cardiac care.

None of the patients were on the newer evidence-based medications; angiotensin receptor-neprilysin inhibitors (ARNi) or sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors) because they are relatively expensive and not readily available.

The study has some limitations. This was a retrospective hospital-based study with a limited number of patients, who mainly represent severely symptomatic patients. Future longitudinal studies are needed with a larger sample size to know the current status of drug utilization in hospital settings involving different centers, containing data about the prognosis and follow-up of patients with heart failure.

  Conclusion Top

Heart failure is caused by various underlying conditions, among which hypertensive heart disease, PPCM, and dilated cardiomyopathy are the most common, followed by rheumatic and ischemic heart diseases. There is underuse and underdosing of evidence-based medications, particularly ACE inhibitors/ARBs and BBs. Diuretics are necessary for patients with evidence of pulmonary or peripheral congestion and provide rapid relief of symptoms.

Our findings, thus, suggest the need for interventions to improve the prescribing rates for evidence-based heart failure medications. The strategies may include the establishment of programs for the management of heart failure, targeted education for physicians to strengthen evidence-based practices, and increased patient awareness of the importance of evidence-based medical therapy.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3]


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