Spironolactone and Chf

• Objective: To assess the impact of interventions to increase the use of spironolactone in patients with congestive heart failure (CHF) due to ventricular systolic dysfunction. • Methods: Charts of patients admitted to the medicine department of a single hospital with a primary diagnosis of class IV CHF and left ventricular ejection fraction of 40% or less were randomly selected and reviewed. Data were obtained for 30 preintervention and 30 postintervention patients. Measures included rates of use of spironolactone, β blockers, and angiotensin-converting enzyme (ACE) inhibitors/ angiotensin-receptor blockers (ARBs) and documentation of contraindications to these therapies. • Interventions: Interventions consisted of adding a clinical decision support reminder to the physician order entry system that alerted physicians ordering ACE inhibitors/ARBs for CHF to consider adding β blockers and spironolactone, an educational program to raise awareness of guideline recommendations, and multidisciplinary efforts to identify patients with CHF on admission and communicate appropriate recommendations to the medical team. • Results: The rate of spironolactone use was 0% in the preintervention sample and 40% in the postintervention sample. Use of ACE inhibitors/ARBs and β blockers did not differ between the preintervention group (73% and 66%) and postintervention group (67% and 60%). Documentation of contraindications to ACE inhibitors/ARBs and β blockers increased from 40% and 0% preintervention, respectively, to 100% and 60% postintervention. • Conclusion: There was a substantial increase in the utilization of spironolactone in patients with systolic dysfunction after the implementation of relatively inexpensive interventions. We continue to look for systems improvements to further increase appropriate use of spironolactone and other evidence-based therapies. Hospital admissions for congestive heart failure (CHF) are common and exert a significant economic burden on the health system [1,2]. Several randomized clinical trials have demonstrated the benefits of drugs and therapies in reducing hospital admissions, decreasing morbidity and mortality, and improving the quality of life in patients with CHF [3–8]. Angiotensin-converting enzyme (ACE) inhibitors have been shown to improve clinical symptoms and survival, slow progression of disease, and decrease hospital readmission rates in patients with CHF [3,4]. In addition, while β blockers previously have been avoided in patients with heart failure, new studies have demonstrated their efficacy in the treatment of CHF. Carvedilol [5], bisoprolol [6], and metoprolol [9] all appear to reduce the occurrence of sudden death and hospitalization. Aldosterone antagonists also have been shown to provide benefit in this patient group. In the Randomized Aldactone Evaluation Study (RALES) and the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS), patients with severe left ventricular dysfunction who were treated with aldosterone antagonists had lower morbidity and mortality [7,8]. Following the RALES study, the Heart Failure Society of America updated their guidelines for the pharmacologic management of patients with CHF due to left ventricular systolic dysfunction [10]. The guidelines state that the following drug therapies should be considered in patients with CHF: ACE inhibitors or angiotensin-receptor blockers (ARBs), β blockers, and diuretics, particularly spironolactone in patients with recent or recurrent New York Heart Association (NYHA) class IV heart failure [10]. In patients with contraindications to ACE inhibitors or ARBs, a combination of hydralazine and nitrates should be considered. Despite the availability of effective pharmacologic therapy, 1-year mortality for symptomatic heart failure remains around 40% [11]. This outcome may be partly due to major From the Yale University School of Medicine and the Hospital of Saint Raphael, Department of Medicine, New Haven, CT. lags in the appropriate adoption of guideline recommendations. In a survey of more than 1500 patient office visits for heart failure, the prevalence of ACE inhibitor use was only 31%, and the doses used were often lower than those used in the clinical trials [12]. Efforts have been undertaken to maximize the use of ACE inhibitors/ARBs and β blockers, the 2 primary drugs in CHF treatment. However, less has been done to increase the use of spironolactone. In our hospital, we implemented a quality improvement initiative to improve the medical treatment of CHF, particularly with regard to spironolactone therapy. We considered any increase in the use of medications or documentation of contraindications to their use to be an improvement.