Use of aldosterone antagonists in heart failure

Context: Aldosterone antagonists are recommended for patients with moderate to severe heart failure (HF) and systolic dysfunction. Prior studies suggest underuse of aldosterone antagonists in eligible patients as well as overuse in settings in which therapy may be harmful. Objective: To examine aldosterone antagonist prescription based on HF management guideline criteria, investigator-defined appropriateness criteria, and trends over time in patients hospitalized with heart failure. Design, Setting, and Patients: Observational analysis of 43 625 patients admitted with HF and discharged home from 241 hospitals participating in the Get With The Guidelines-HF quality improvement registry between January 2005 and December 2007. Main Outcome Measures: Prescription and predictors of use of aldosterone antagonists, based on guideline criteria. Results: Among 12 565 patients eligible for aldosterone antagonist therapy, 4087 (32.5%) received an aldosterone antagonist at discharge, and treatment increased modestly from 28% to 34% over the study period. There was also wide variation in aldosterone antagonist use among hospitals (0%-90.6%). Aldosterone antagonist use in eligible patients was associated with younger age (adjusted odds ratio [OR], 0.85; 95% confidence interval [CI], 0.82-0.88), African American race/ethnicity (adjusted OR, 1.17; 95% CI, 1.04-1.32), lower systolic blood pressure (adjusted OR, 0.94; 95% CI, 0.92-0.95), history of implantable cardioverter-defibrillator use (adjusted OR, 1.51; 95% CI, 1.34-1.69), depression (adjusted OR, 1.15; 95% CI, 1.01-1.30), alcohol use (adjusted OR, 1.23; 95% CI, 1.02-1.50), and pacemaker implantation (adjusted OR, 1.21; 95% CI, 1.06-1.38), and with having no history of renal insufficiency (adjusted OR, 0.85; 95% CI, 0.75-0.96). Applying serum creatinine and potassium appropriateness criteria, inappropriate and potentially inappropriate use of aldosterone antagonist therapy was low and did not change over the 3-year study period. Conclusions: Less than one-third of eligible patients hospitalized for HF and participating in a quality improvement registry received HF guideline-recommended aldosterone antagonist therapy. Use of aldosterone antagonist therapy among patients with documented contraindications was low.