Lower Rehospitalization, Mortality Seen From Sacubitril/Valsartan Use for HFrEF
Entresto (sacubitril/valsartan) was first approved for use in heart failure with reduced ejection fraction (HFrEF) in 2015.
A high 3-month adherence rate to the angiotensin receptor neprilysin inhibitor (ARNI) Entresto (sacubitril/valsartan; Novartis) was seen among patients with
These
Despite the American College of Cardiology having the ARNI as its
“Recent data suggest that only 14% of US outpatients with HFrEF are prescribed sacubitril/valsartan and <10% of patients with HFrEF who are eligible for sacubitril/valsartan received a prescription at discharge from acute HF hospitalization,” the authors added.
Of the 897-patient cohort, close to 33% (n = 295) who had a sacubitril/valsartan prescription at discharge had at least an 80% proportion of days covered (PDC) rate, meaning that for at least 80% of the days in the ensuing 3 months after discharge, they adhered to that prescription regimen. In contrast, just over 67% (n = 602) had a PDC lower than 80%.
Follow-up periods were 90 days for medication adherence and 1 year for rehospitalization and mortality risk. Patient data were derived from the Get With the Guidelines–Heart Failure registry and linked with Medicare claims for at least 1 acute HF hospitalization from October 2015 to September 2018. All patients included in the final analysis had a hospital discharge with sacubitril/valsartan.
Among those with the higher PDC, at 90 days there was a 34% (HR, 0.66; 95% CI, 0.48-0.89) lower risk of all-cause rehospitalization and a 58% (HR, 0.42; 95% CI, 0.22-0.79) lower risk of death vs those with the lower PDC. At the 1-year mark, despite slight increases, these numbers were still reduced in the group with a PDC of at least 80%, by 31% (HR, 0.69; 95% CI, 0.56-0.86) and 47% (HR, 0.53; 95% CI, 0.38-0.74), respectively.
Individuals were excluded if they had a left ventricular assist device or a history of heart/lung transplantation.
In addition, 1-year rates of rehospitalization and mortality continued to drop, by 2% (HR, 0.98; 95% CI, 0.97-0.99) and 4% (HR, 0.96; 95% CI, 0.94-0.97), respectively, with each 5-percentage-point jump in PDC.
Medicare coverage for the patients in the study comprised fee-for-service and Part D prescription medication coverage for at least 6 months prior to their index hospitalization through at least 90 days post index hospitalization discharge.
The median (interquartile range) patient age in both groups was close to equal—77 (71-82) and 76 (70-82) years in the groups with less than 80% PDC and at least 80% PDC, respectively—and more than 60% of each group were male. Their median ejection fraction was 25% (20%-33%), 86% of the group with less than 80% PDC and 89% of the group with at least 80% PDC had a history of HF, the most common comorbidities were hyperlipidemia and hypertension, and 93% each were on beta-blockers at discharge.
Between-group differences also show that treatment with sacubitril/valsartan was initiated in more of the group with at least 80% PDC before their index hospitalization, there was a greater history of stroke/transient ischemic attack among patients with less than 80% PDC, and more of those with at least 80% PDC were on mineralocorticoid receptor antagonists (46.4% vs 36.5%).
Two additional measures show the following for outcomes after the adherence ascertainment period:
- At 30 days, the group with at least 80% PDC had a 41% (HR, 0.59; 95% CI, 0.38-0.92) lower all-cause rehospitalization risk and a 58% (HR, 0.42; 95% CI, .021-0.87) lower HF-related hospitalization risk compared with the group with PDC less than 80%.
- Among the 76.7% of patients with 1-year continuous Medicare Part D eligibility following their index hospitalization, 89.8% who began with less than 80% PDC stayed there and 48.2% of those who began with at least 80% PDC were at less than 80% PDC by the 1-year mark.
The authors note that with their findings possibly being “the first to describe the relationship between postdischarge sacubitril/valsartan adherence and subsequent clinical outcomes,” these data could be predictive of 1-year clinical outcomes and add to the current evidence that heart failure medication adherence needs to be targeted to improve patient outcomes.
“Patients with higher sacubitril/valsartan adherence within 90 days after discharge had lower adjusted risk of all-cause death and all-cause rehospitalization at 1 year, compared with patients with lower adherence,” they concluded. “These data support continued efforts toward improving adherence to sacubitril/valsartan as an important strategy for improving clinical outcomes in routine practice.”
Reference
Carnicelli AP, Li Z, Greiner MA, et al. Sacubitril/valsartan adherence and postdischarge outcomes among patients hospitalized for heart failure with reduced ejection fraction. JACC Heart Fail. Published online September 1, 2021. doi:10.1016/j.jchf.2021.06.018
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