Initiation and continuation of pharmacological therapies in patients hospitalized for heart failure in Japan

Abstract

Currently, the utilization patterns of medications for heart failure (HF) after worsening HF events remain unelucidated in Japan. Here, we conducted a retrospective cohort study evaluating the changes in HF drug utilization patterns in 6 months before and after hospitalizations for HF. The adherence to newly initiated HF medications was evaluated based on the proportion of days covered (PDC) and persistence as continuous treatment episodes among new users. The study included 9091 patients hospitalized for HF between January 2016 and September 2019, including 2735 (30.1%) patients who were newly prescribed at least one HF medication after hospitalization. Despite increases in the use of foundational HF therapy (beta-blockers, angiotensin-converting-enzyme inhibitors/angiotensin receptor blockers, or mineralocorticoid receptor antagonists), 35.6% and 7.6% of patients were treated with the HF foundational monotherapy or diuretics alone after hospitalization, respectively. The mean PDC of newly initiated HF medications ranged from 0.57 for thiazide diuretics to 0.77 for sodium-glucose cotransporter-2 inhibitors. Continuous use of HF medications during the first year after initiation was observed in 30-60% of patients. The mean PDC and one-year continuous HF medication use were consistently lower in patients aged ≥ 75 years and in patients with a history of HF hospitalization for all HF medication classes except for tolvaptan and digoxin. Despite the guideline recommendations of HF pharmacotherapy, both treatment and adherence were suboptimal after HF hospitalization, especially in vulnerable populations such as older patients and those with prior HF hospitalizations.

Figure 1

Summary of study design. *Patients were followed up until the timing of death, emigration from dataset, or the end of study period (October 31, 2021), whichever came first. HF heart failure.

Figure 2

Flow diagram of patient inclusion in the study. HF heart failure, EMR electronic medical records.

Figure 3

Drug utilization patterns before and after the index hospitalization for heart failure. Panel (A) shows the drug utilization patterns for each HF medication class, and panel (B) shows the combination patterns of HF medications. The denominator is all patients included in the study (n = 9091). ACEi angiotensin-converting-enzyme inhibitor, ARB angiotensin receptor blocker, BB beta-blockers, MRA mineralocorticoid receptor antagonist, SGLT-2i sodium-glucose co-transporter-2 inhibitor.

Figure 4

Distribution of newly initiated HF medication classes in all patients and subgroups of patients stratified based on age and a history of prior hospitalization for HF. Panel (A) shows the results for the group with all patients (n = 9091), panel (B) shows the results for the subgroups of patients with age < 75 years (n = 2724) or ≥ 75 years (n = 6367), and panel (C) shows the results for the subgroups of patients with (n = 1372) or without a history of hospitalization for HF before the index hospitalization (n = 7719). ACEi angiotensin-converting-enzyme inhibitor, ARB angiotensin receptor blocker, MRA mineralocorticoid receptor antagonist, SGLT-2i sodium-glucose co-transporter-2 inhibitor, HF heart failure.

Figure 5

Proportion of patients with continuous use of HF medications during the first year after initiation. The analysis was performed in patients who could be followed up for 365 days after HF treatment initiation in each new-user cohort. ACEi angiotensin-converting-enzyme inhibitor, ARB angiotensin receptor blocker, HF heart failure, MRA mineralocorticoid receptor antagonist, SGLT-2i sodium-glucose co-transporter-2 inhibitor.