Durham, NC—Underuse of a drug to help lower heart rate when beta blockers aren’t effective enough means that many heart failure (HF) patients aren’t receiving optimal care.

That’s according to preliminary research presented at the American Heart Association's Quality of Care and Outcomes Research Scientific Sessions 2019 in Arlington, Virginia. In fact, Duke University Medical Center–led researchers pointed out that HF patients who could possibly benefit from ivabradine were more likely to take the medication if it was prescribed before hospital discharge rather than in a follow-up doctor's visit.

“The hospitalization rate in heart failure patients is quite high despite a number of good therapies, yet we have ivabradine, a relatively new therapy that can reduce hospitalization, and we still aren't using it to the extent possible,” explained lead author Robert Mentz, MD, an associate professor of cardiology at Duke University Medical Center in Durham, North Carolina.

In 2016, the American Heart Association and the American College of Cardiology issued a focused update to HF guidelines to reflect newer medication options. One recommendation was on ivabradine, which had been proven to help improve outcomes for HF patients, including reducing their risk of rehospitalization.

The PredischaRge Initiation of Ivabradine in the ManagEment of Heart Failure (PRIME-HF) trial evaluated 104 patients—average age 57.5 years, 36% women, 64% African American—who had worsening HF, were appropriate candidates to receive ivabradine and were inpatients at one of 23 U.S. hospitals.

“Prior studies suggest that the hospital setting provides an important opportunity to initiate guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF),” study authors write. “Ivabradine is a specific inhibitor of the If current in the sinoatrial node that is FDA-approved for use in chronic HFrEF. A randomized trial conducted outside the U.S. demonstrated that heart rate reduction with ivabradine improved clinical outcomes for ambulatory patients with chronic, symptomatic HFrEF.”

For the randomized, open-label study of predischarge initiation of twice-daily ivabradine versus usual care (i.e., postdischarge initiation of ivabradine at discretion of routine physician), HF patients were followed for 180 days. Defined as the primary endpoint was the proportion of patients using ivabradine at 180 days, with other endpoints including heart rate change, patient-reported outcomes, beta-blocker use, barriers to ivabradine acquisition, and clinical outcomes.

Six months after hospitalization, the researchers determined that patients who had initiated ivabradine prior to discharge:
• Were far more likely to be using the drug—40.4% versus 11.5%
• Had a greater reduction in heart rate (10 bpm vs. 0.7 bpm, average heart rate 77 bpm vs. 86 bpm)
• Had not reduced their dose of beta-blockers
• Did not develop abnormally low blood pressure or heart rate

The trial was ended early because of the difficulty of recruiting enough participants. Researchers noted that patients in both groups encountered barriers to obtaining ivabradine, with 30.6% having difficulty getting their initial prescription, and 58.1% percent having trouble getting ivabradine at some point during the 6-month study. Reasons included high price, insurers declining to pay, and physicians deciding to stop the drug.

“When we designed the trial, we thought that more people would be using this medication in routine practice. The reality has been that adoption of the therapy has been very slow and only a fraction of potential patients are receiving it,” Mentz said. “Some of this is related to cost while some is also related to providers’ lack of familiarity with the medication and how best to use it. We are looking into how we can better support the early adoption of novel therapies in patients with heart failure to improve their outcomes.”

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