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Evaluation of Patients with Heart Failure to Determine Eligibility for Treatment with Sacubitril/Valsartan: Insights from a Veterans Administration Healthcare System
Author(s) -
Han Jamie,
Chung Francisco,
Nguyen Quyen L.,
Mody Freny Vaghaiwalla,
Jackevicius Cynthia A.
Publication year - 2019
Publication title -
pharmacotherapy: the journal of human pharmacology and drug therapy
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.227
H-Index - 109
eISSN - 1875-9114
pISSN - 0277-0008
DOI - 10.1002/phar.2328
Subject(s) - sacubitril , valsartan , sacubitril, valsartan , medicine , heart failure , ejection fraction , veterans affairs , natriuretic peptide , cardiology , neprilysin , angiotensin receptor , angiotensin ii , blood pressure , biochemistry , chemistry , enzyme
Study Objective Despite evidence that supports the use of sacubitril/valsartan – the first angiotensin II receptor blocker–neprilysin inhibitor – for mortality reduction in patients with heart failure ( HF ), it remains underprescribed. The objective of this study was to evaluate eligibility for initiation of sacubitril/valsartan treatment in patients with HF within the largest Veterans Administration healthcare system in the United States. Design Cross‐sectional study. Setting Veterans Affairs Greater Los Angeles Healthcare System ( VAGLAHS ). Patients A total of 2985 patients with a HF diagnosis who were alive as of November 1, 2017. Measurements and Main Results Eligibility for sacubitril/valsartan initiation was based on inclusion and exclusion criteria from the Prospective Comparison of Angiotensin Receptor–Neprilysin Inhibitor with Angiotensin‐Converting–Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure ( PARADIGM ‐ HF ) trial and the VA Criteria for Use. The proportion of eligible patients was estimated, and characteristics of eligible patients were compared with those in the PARADIGM ‐ HF trial. Of the 2985 patients with HF who were alive as of November 1, 2017, 965 (32.3%) had HF with reduced ejection fraction ( HF r EF ). Of these patients with HF r EF , 263 (27.3%) fulfilled eligibility criteria and were considered candidates for sacubitril/valsartan initiation. Of the 702 patients who did not fulfil eligibility criteria, the most common reasons were New York Heart Association functional class I (35.3%) and B‐type natriuretic peptide level of 100 pg/ ml or lower (22.2%). Compared with patients in the PARADIGM ‐ HF trial, VAGLAHS patients were older (70.4 vs 63.8 yrs) and more likely to be male (98.5% vs 79.0%), and a higher proportion had New York Heart Association functional class III symptoms (35.4% vs 23.1%). Of the 965 patients with HF r EF , 34 (3.5%) had an active sacubitril/valsartan prescription as of November 1, 2017, of whom 27 (79.4%) did not meet criteria. Conclusion Whereas 27% of patients with HF r EF were eligible to initiate sacubitril/valsartan, only 3.5% of these patients were prescribed the medication. Although sacubitril/valsartan reduced morbidity and mortality in clinical trials, it remains underused within this VA healthcare system. This analysis provides important insights into the VA and other healthcare systems regarding the opportunity for optimizing guideline‐directed HF therapy.