Recent Diagnosis and Undefined Etiology Delay Initiation of Mineralocorticoid Receptor Antagonism in Heart Failure

Abstract

Introduction ACC/AHA guidelines recommend all patients with heart failure (HF), both reduced and preserved ejection fraction (HFrEF and HFpEF), be prescribed a mineralocorticoid antagonist (MRA). National data suggest as few as 16-33% of patients admitted for acute HF are prescribed MRAs. We performed a retrospective analysis from an urban academic quaternary care center to elucidate why some individuals are prescribed MRA while others are not. Methods We analyzed all patients admitted for acute HF in 2017. Eligibility for MRA was determined by serum potassium less than 5 mEq/dL and estimated glomerular filtration rate (eGFR) greater than 30 mL/min/1.73m2. Patients were divided into those newly prescribed MRA on discharge, and those eligible for MRA but not prescribed. Variables included comorbidities, medications, etiology, ejection fraction (EF), potassium, eGFR, and new HF diagnosis. Students’ t-test for continuous and chi-square analysis for categorical variables were completed. Results There were 802 admissions for acute HF representing 570 unique patients. Prior to admission, 101 (18%) were on MRA. Two hundred-eighteen others were eligible for MRA, of which 87 (40%) were newly prescribed (Rx) after discharge, and 131 (60%) were not prescribed (NRx). A total of 188 (33%) were on MRA at discharge. Rx patients had a mean EF of 30% compared to 38% for NRx (p\u202f=\u202f0.002). Similarly, 70% of Rx patients had a reduced EF compared to 46% for NRx patients (p Discussion Lack of MRA prescription was associated with greater EF, newly diagnosed HF, and unclear HF etiology. This data suggests that prescribers hesitate to follow guideline directed medical therapy for those with higher EF, even if the patients fit within the recommendations. Similarly, physicians delay MRA after an initial diagnosis. Awareness of these influences may inform future decision making when prescribing MRAs.