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Health See other Health Articles Title: One in Four ICD Patients Not on Optimal Drug Therapy NEW YORK (Reuters Health) Nov 18 - More than a quarter of patients with implanted cardioverter/defibrillators (ICDs) receive suboptimal medical therapy, according to a new analysis of data from the National Cardiovascular Data Registry. "Optimal therapy" means a beta-blocker plus either an angiotensin-converting enzyme inhibitor (ACE) or an angiotensin receptor blocker (ARB), the researchers reported online November 14 in Archives of Internal Medicine. "The fact that one out of four patients doesn't appear to be getting both of these drugs is very concerning just from a quality of care standpoint," lead author Dr. Amy Leigh Miller of Brigham and Women's Hospital in Boston told Reuters Health. Her team found that treatment by a surgeon was the strongest risk factor for suboptimal medical therapy, which suggests to Dr. Miller that "cardiologists and internists may not be following their patients closely enough." "Surgeons train with a very different focus," she added. "Medical management is really a focus of internists and cardiologists. When surgeons are taking care of our patients, we as cardiologists need to remain involved and make sure our patients are staying on the right medications." Rates of optimal medical therapy were higher when the doctor who implanted the ICD had some formal training in electrophysiology, her group said in its report. Their findings are based on nearly 176,000 adults who had ICDs implanted in 2007-2009 in "contemporary, real-world practice." The researchers excluded anyone with a left-ventricular ejection fraction (LVEF) above 35% and those who died in the hospital. Overall, 25.7% of patients were eligible for optimal medical therapy but not receiving it, the researchers found. Across 1,201 hospitals nationwide, rates of optimal medical therapy prescriptions ranged from 0% to 100%, with a median of 73.5% and an interquartile range of 64% to 82%. On multivariate analysis, optimal therapy was linked with treatment at a teaching hospital (odds ratio 1.16), percutaneous coronary intervention at admission (OR 1.11), a history of hypertension (OR 1.32) and admission for a cardiovascular indication (OR 1.11). On the other hand, the lowest odds for optimal medical therapy were in patients who had bypass surgery during admission (OR 0.66) or who had an ICD implanted by a board-certified surgeon (OR 0.73). When they split out the two classes of drugs, the researchers found that 18.7% of eligible patients were not receiving an ACE/ARB, while 10.7% were not receiving a beta blocker. Having a surgically trained provider cut the likelihood of an ACE/ARB prescription by 24%, while having coronary bypass surgery during the index admission cut the odds by 41%. Odds for beta-blocker prescriptions were lowest in patients with chronic lung disease (odds ratio 0.72) and those cared for by surgeons (OR 0.74). Dr. Miller and her colleagues write that while some patients may have had contraindications to medical therapy that weren't documented, their study "underscores the need for increased vigilance for treatment opportunities." In a commentary published with the study, Dr. Paul J. Hauptman of Saint Louis University School of Medicine in Missouri says the paper provides "at best a snapshot of medication use" -- although he adds that the size of the cohort makes it a "snapshot with a wide lens." In an interview, he told Reuters Health that the emphasis on ICDs for patients with an LVEF below 35% "to some degree has led to a paint-by-numbers approach to patients," with not enough attention being paid to the role of medical therapy. Dr. Miller and her group point out that optimal medical therapy "reduces mortality, the risks of heart failure decompensation and ventricular arrhythmias requiring shocks." Dr. Hauptman added, "Fundamentally, first principles apply, and that is patients should have exhausted optimal medical therapy, especially medical therapy that could demonstrably influence a patient's candidacy for a defibrillator. In particular a reasonable course of evidence-based beta blockers would be very high on the list, and it's remarkable that we're still noting that this has not been applied universally." "The bottom line is the medication works," Dr. Hauptman concluded. "We have to find ways to get these patients on to these medications and stay on them." SOURCE: bit.ly/tDdFXf Post Comment Private Reply Ignore Thread
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