Importance of Medication Management for Congestive Heart Failure

It's American Heart Month, a time when there is increased attention paid to cardiovascular health and heart disease. Conversations about these subjects should always include discussion about medications and the essential role they play in maintaining good heart health and controlling heart disease, including one of its most common complications: congestive heart failure (CHF), sometimes simply referred to as heart failure. *

Let's review a range of statistics, facts, and reasons supporting why healthcare organizations should prioritize medication management for their patients with CHF.

1. CHF is deadly and expensive

As the Centers for Disease Control and Prevention notes, heart disease is the leading cause of death for men, women, and people of most racial and ethnic groups in the United States. Heart disease costs the United States more than $360 billion each year, which includes the cost of healthcare services and medications.

Congestive heart failure is one of the most common types of heart disease. The Heart Failure Society of America shares some noteworthy statistics about CHF, including the following:

• Current statistics estimate that nearly 6.5 million Americans over the age of 20 have heart failure.
• One study estimated there are close to a million new heart failure cases annually.
• Heart failure accounts for about 8.5% of all heart disease deaths in the United States.

CDC notes that in 2018, heart failure was mentioned on nearly 400,000 death certificates, and heart failure itself cost the nation an estimated $31 billion in 2012.

2. Numerous medications are prescribed for congestive heart failure

The American Heart Association (AHA) identifies some of the major types of commonly prescribed heart failure medications — and there are many of them. The list includes:

• Loop diuretics
• Renin-Angiotensin System Inhibitors (ACEi, ARBs, or ARNIs)
• Beta blockers (effective in reducing the risk of death in HF patients)
• Aldosterone antagonists
• Combination of hydralazine and nitrates (for select HF populations)
• SGLTi (most recently)

AHA also notes that CHF patients may be prescribed other less commonly used drugs if they have additional health problems. These drugs include anticoagulants (blood thinners), cholesterol-lowering drugs (statins), and digoxin. AHA has reported that patients with heart failure take, on average, close to 7 prescription medications per day, which is approximately 10 doses per day. Patients with heart failure should take their medications as directed by their healthcare provider to optimize the benefits and reduce risk.

3. Patients with congestive heart failure typically have other health issues

If a patient has CHF, they likely have one or more additional health issues — issues that may require management through one or more medications. A few of the common conditions associated with CHF, according to Verywell Health, include:

• High blood pressure (hypertension)
• Obesity
• Diabetes
• HIV
• Sleep apnea
• Cancer
• Hyperthyroidism

4. Medications can contribute to and exacerbate congestive heart failure

While medications play an important role in improving heart function and prolonging the lives of those with CHF, medications can have the opposite effect. Mayo Clinic notes that some diabetes medications, nonsteroidal anti-inflammatory drugs (NSAIDs), anesthesia medications, and those used to treat high blood pressure, cancer, blood conditions, irregular or abnormal heartbeats, nervous system diseases, mental health conditions, lung and urinary problems, inflammatory diseases, and infections have been found to increase the risk of heart failure and heart problems.

5. Older heart failure patients are often prescribed 10 or more medications

Research published in Circulation: Heart Failure, an AHA journal, in 2020 revealed an alarming statistic: more than half of older patients hospitalized for CHF are discharged with 10 or more prescriptions. Most of these are not medications to treat heart failure or other cardiovascular conditions.

Such "excessive polypharmacy," which is defined by a BMJ Open article as "concurrent use of 10 or more different drugs," brings with it serious risks. In the AHA press release about the 2020 research, Dr. Parag Goyal, the senior study author and a geriatric cardiologist, states, "High medication burden, also known as polypharmacy, is commonly associated with adverse events and reactions. As the treatment options for various conditions including heart failure expand and the population ages, it is becoming increasingly important to weigh the risks and possible benefits of multiple medications."

In a 2021 blog post, we explored pharmacy in the elderly, highlighting the reasons why polypharmacy is so much more prevalent in older adults and dangers associated with these contributing factors. You can access the post here.

6. Medication reconciliation is vital for congestive heart failure patients

Considering the sheer number of medications likely to be prescribed to patients with CHF — a figure that will typically increase as the patient ages — medication reconciliation takes on an elevated importance in the care of CHF patients. Med rec, one of the core components of medication management, should play an ongoing role in helping ensure patients are consistently taking the right medications at the right times for their specific and evolving health issues.

Furthermore, every hospitalized patient, including those with CHF, should receive medication reconciliation post-discharge (MRP). Why? As Cureatr Chief Executive Officer Richard Resnick states, "The discharge from the hospital to the home is one of the most dangerous care transitions for all patients, but particularly for those with complex medication regimens" — such as most CHF patients. The Centers for Medicare & Medicaid Services, he notes, has set the target for completed MRPs at 80%, but it really should occur 100% of the time as research has revealed that more than half of all discharges have at least one medication error.

The Institute for Healthcare Improvement (IHI) highlights the importance of medication reconciliation in this improvement story. In fact, the scenario discussed in the story concerns an elderly female patient with CHF who is arriving at a hospital via ambulance. IHI states, "Getting this woman's medication information right may be critical to her treatment in the emergency department (ED). But it also matters because she's likely to be cared for in several different departments, and the initial record of this patient's medications — accurate or not, and whether collected in the ED or when admitted to a unit — will travel with her throughout her hospital stay. When the information is incomplete or inaccurate, there can be discontinuities in care." The impact of potential med rec shortcomings includes a compromise in quality and safety, increase in medication errors, and increase in adverse drug events (ADEs).

7. Deprescribing should also play a valuable role

Another important facet of medication management for heart failure patients is safe, appropriate deprescribing. Deprescribing is "the planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit," according to the informative website Deprescibing.org. The site continues, stating, "Deprescribing is part of good prescribing — backing off when doses are too high, or stopping medications that are no longer needed."

As we note in the aforementioned Cureatr blog post concerning polypharmacy, "Lack of deprescribing can indirectly contribute to polypharmacy when opportunities to safely eliminate medications — immediately or via gradual reduction — are missed."

Deprescribing in older adults with cardiovascular disease was the subject of research published in 2019 in the Journal of the American College of Cardiology. The authors grouped common triggers to consider deprescribing into four categories:

• Adverse drug reactions
• Polypharmacy
• Prescribing cascades
• End of life and as part of palliative care

The authors include the following in their conclusion: "The cardiovascular clinical team must recognize, particularly in reference to older adults, that deprescribing is an important resource that can improve clinical care and enhance quality of life."

8. Pharmacists should take the lead on CHF medication management

Considering the complexity of medication management for congestive heart failure patients — everything from multiple medications prescribed for CHF and other conditions; the risks associated with these medications; the importance of performing medication reconciliation at every transition of care, including post-discharge; the value of executing appropriate deprescribing; and other essential steps — the member of the patient's healthcare team in the best position to take the lead on CHF medication management is undoubtedly the pharmacist.

We recently discussed how pharmacists improve medication management during care transitions, highlighting such factors as a pharmacist's medication expertise, access to more detailed and complete drug information, and proper completion of med rec and MRP. Meanwhile, a recent column in Pharmacy Times explained why pharmacists are so well-suited to polypharmacy management of CHF patients, with the authors noting, "The complexity of CHF management provides many opportunities for pharmacists to adopt impactful roles in these patients' lives through medication therapy management, patient education, interdisciplinary collaboration, and coordinated transition of care."

An Integrated Pharmacy Research and Practice article on the role of the pharmacist in heart failure management, states, "It has been evaluated and documented that pharmacists providing medication reconciliation especially during transition of care, educating patients on their medications, and providing collaborative medication management lead to positive changes in the patient outcomes, including reduction in medication errors and drug interactions, improvement in medication adherence, and improvement of use of guideline-driven therapy."

Furthermore, a systematic review of studies published in the Journal of the American College of Clinical Pharmacy found that pharmacist-led medication optimization increased the use of guideline-directed medical therapy in ambulatory patients with heart failure and may be associated with fewer hospitalizations and deaths. A 2020 study published in the Journal of Cardiac Failure demonstrated that a pharmacist-led clinic proved more beneficial than a standard cardiologist-led clinic for patients with heart failure and reduced ejection fraction.

The value of involving pharmacists in the care of CHF patients has long been understood. A frequently referenced 2008 systematic review of randomized trials published in the Archives of Internal Medicine (now JAMA Internal Medicine) found that, "Pharmacist care in the treatment of patients with heart failure greatly reduces the risk of all-cause and heart failure hospitalizations."

Improving Medication Management of Heart Failure

If your organization is seeking assistance with delivering medication management services, including to your patients with congestive heart failure, reach out to Cureatr. Our combination of clinical pharmacy experts, comprehensive data, and advanced technology helps organizations nationwide improve transitions of care and overcome the top medication management challenges that contribute to suboptimal outcomes, readmissions, unnecessary expenses, and reduced quality scores. Learn more about our clinical service and the challenges we solve, then schedule a time to speak with one of our consultants.

*While CHF and heart failure are often used interchangeably, as we did in the post above, heart failure can be broken down into multiple types, including CHF. AHA describes the different types of heart failure here.