Transcript GWTG HFSA Poster 2006 - American Heart Association

Use of Hydralazine-Isosorbide Dinitrate combination in African American and Other
Race/Ethnic Group Patients with Heart Failure and Reduced Ejection Fraction
Harsh Golwala, MD;1 Udho Thadani, MD;1 Li Lang, MD, PhD;2 Stavros Stavrakis, MD, PhD;1 Javed Butler MD;3 Clyde W. Yancy, MD;4
Deepak L. Bhatt, MD, MPH;5 Adrian Hernandez, MD, MHS;2 Gregg C. Fonarow, MD6
1University of Oklahoma, Oklahoma City, OK; 2Duke Clinical Research Institute, Durham, NC; 3Emory University, Atlanta, GA;
4Northwestern University, Chicago, IL; 5VA Boston Healthcare System, Brigham and Women’s Hospital, Boston, MA; 6UCLA Medical Center, Los Angeles, CA
Results
Background
Table 1.Patient Characteristics by Hydralazine-Isosorbide
Dinitrate Use at Hospital Discharge
Hydralazine-Isosorbide dintrate use
No. (%)
Patient characteristics
Objective
 To determine the contemporary use of H-ISDN use over
time in both African American and other racial/ethnic
groups, trends in its use over time, as well as patient and
hospital factors associated with its use.
Methods
 GWTG-HF is an ongoing, prospective registry and quality
improvement program initiated in January 2005 by the
American Heart Association (AHA)
 122,395 patients admitted with HF were discharged from
207 hospitals participating in GWTG-HF program from
April 1, 2008 through March 24, 2012.
 Of these, patients with missing data on ejection fraction
[n=3,868] or ejection fraction >40% [n=63,905] were
excluded yielding a population of 54,622 HFrEF patients.
 Further exclusions included unknown race or ethnicity
[n=2,288], and documented contra-indication to H-ISDN
therapy [n=2,508]. We also excluded patients who were
comfort care only, or those who died, or who had missing
information on discharge destination.
 The final study population thus included 43,898 patients
with HFrEF from 195 hospitals
 Outcomes Sciences, a Quintiles Company, Cambridge,
MA served as the data collection center and Duke Clinical
Research Institute served as the data analysis center.
Disclosures: GWTG-HF program is provided by the
AHA.GWTG-HF has been funded in the past through support
from Medtronic, GlaxoSmithKline, Ortho-McNeil, and the
American Heart Association Pharmaceutical Roundtable.
This project was also supported by Young Investigator
Database Research Seed Grant to Dr. Golwala -supported
by the Council on Clinical Cardiology.
Age, mean (SD), y
Male (%)
Race (Median)
White
African American
Hispanic
Others
Hypertension (%)
Diabetes (%)
Hyperlipidemia (%)
Atrial Fibrillation (%)
COPD (%)
Peripheral vascular disease (%)
Coronary artery disease (%)
CVA (%)
ICD (%)
Heart failure (%)
Pacemaker (%)
CRT-P (%)
CRT-D (%)
Chronic dialysis (%)
Smoking (%)
Ejection fraction, mean (SD)
Total
Yes
(n=43,898) (n=5,515)
68.3 (15)
62.4
61.3
25.4
8.7
4.4
74.2
41.2
48.2
29.9
27.6
11.6
50.9
13.4
19.6
73.2
14.3
0.8
8.8
2.9
21.8
24.7 (7.8)
65.4 (15)
65.8
43.6
45.3
7.5
3.4
82.1
50.5
50.1
26.3
29.0
13.6
52.1
16.0
25.3
79.5
13.5
0.8
12.1
3.9
22.0
24.8 (7.8)
Figure 1. Current Use as Well as Trends in the Use of
Hydralazine-isosorbide Dinitrate at Discharge in Eligible
Patients from 2008-2011
No
P value
(n=38,383)
68.7 (15)
61.9
63.8
22.6
8.8
4.62
73.1
39.9
47.9
30.4
27.4
11.3
50.7
13.1
18.8
72.3
14.4
0.8
8.3
2.8
21.81
24.7 (7.8)
0.6
0.5
0.3
Race
<.0001
<.0001
<.001
<.0001
<.0001
0.003
<.0001
0.018
<.0001
0.05
<.0001
<.0001
<.0001
0.08
0.64
<.0001
<.0001
0.78
0.31
All values listed as mean ± standard deviation or %.
Wilcoxon two-sample test performed for continuous variables.
Chi-square test performed for categorical variables.
Abbreviations: COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident;
ICD, Implantable cardioverter defibrillator; CRT- D,P= Cardiac resynchronization therapy- pacemaker,
defibrillator
% of patients
with H-ISDN
discharge
African American
22.3
White
8.9
Hispanics
10.8
Others
9.8
0.25
Black
0.4
White
0.3
Hispanic
0.2
H-ISDN
 ACC/AHA and HFSA guidelines recommend the use of
Hydralazine-Isosorbide Dinitrate (H-ISDN) in self identified
African American patients with heart failure and reduced
ejection fraction (HFrEF). In addition, H-ISDN may be
considered in non-African American patients with HFrEF
who remains symptomatic on optimized standard therapy.
Figure 2. H-ISDN Use in African American
Patients in Hospitals with at Least 10 SelfIdentified African American Patients
0.2
Other
0.1
0.15
0
0.1
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88
0.05
Limitations
0
2007
2008
2009
2010
2011
Table 2. Patient and Hospital Factors Associated with H-ISDN
Use in Self-Identified African American Patients
Variable
Adjusted OR
P value
Age, per 10 y
Female vs. Male
Uninsured vs Medicare
COPD
Diabetes
Hypertension
ICD implantation
Heart Failure
Anemia
Chronic dialysis
Renal insufficiency
Smoking
Systolic BP. Per 10 mm Hg
Heart rate, per 10 beats/min
Hospital Bed size, per 500 beds
0.90 (0.86-0.95)
0.76 (0.68-0.85)
0.82 (0.70-0.76)
1.19 (1.07-1.31)
1.20 (1.07-1.35)
1.30 (1.07-1.58)
1.36 (1.19-1.55)
1.39 (1.23-1.58)
1.27 (1.07-1.50)
0.59 (0.42-0.83)
2.33 (2.01-2.69)
0.82 (0.72-0.93)
1.15 (1.12-1.18)
0.93 (0.91-0.95)
1.77 (1.24-2.52)
<0.001
<0.001
0.0118
0.001
0.0025
0.0084
<0.0001
<0.0001
0.0052
0.0028
<0.0001
0.0026
<0.0001
<0.0001
0.0018
Abbreviations: COPD, chronic obstructive pulmonary disease; ICD, implantable cardioverter
defibrillator
2012
 The data collection is dependent on the accuracy and
completeness of data abstraction.
 Measured and unmeasured confounding factors may
impact findings.
 Data do not include longitudinal follow-up, hence a
portion of eligible patients may have been started on HISDN as an outpatient, underestimating its real use.
However, previous data suggest that if a medication is
not started at the time of discharge; subsequent new
prescription rate in outpatient setting is low.
 Finally, GWTG-HF hospitals are self-selected and may
not be representative to all hospitals in the US.
Conclusions
 Hydralazine-isosorbide dinitrate use in eligible African
American patients with HFrEF remains very low in real
world practice despite clinical trial evidence and
guideline recommendations.
 Although H-ISDN use has increased over time from
2008 through 2011, it has nevertheless remained less
than 25% even in the African American patients.
 Given the substantial morbidity and mortality faced by
patients with HFrEF and the established efficacy of HISDN among African American patients, aggressive
measures to facilitate adherence to H-ISDN should be
sought.