High prevalence of polypharmacy in older patients hospitalized for HF
Polypharmacy in Older Adults Hospitalized for Heart FailureLiterature - Unlu O, Levitan EB, Reshetnyak E, et al. - Circ Heart Fail 2020, e006977, doi.org/10.1161/CIRCHEARTFAILURE.120.006977
Introduction and methods
Polypharmacy is associated with many adverse outcomes, such as falls, disability and hospitalizations [1,2]. And this is in particular relevant for older adults with HF as they are vulnerable to the adverse effects of polypharmacy caused by age-related changes in pharmacokinetics and pharmacodynamics , alterations in CV structure and function  and conditions as frailly and cognitive impairment [5,6].
Although it is known that polypharmacy can result in harm, there is limited data on real-world information on polypharmacy in the setting of HF. During or shortly after hospitalization medication errors and adverse drug events are common , therefore information on medication pattern during this time period is important.
This study examined polypharmacy during HF hospitalization using a cohort of older patients hospitalized for HF derived from the REGARDS study (Reasons for Geographic and Racial Differences in Stoke).
REGARDS was a national prospective observational cohort of community-dwelling black and white men and women ≥45 years from the US recruited from 2003-2007. Baseline data collection was done at telephone interview and 1 month later blood and urine samples were collected, as well as physiological measures. During follow-up, participants were every 6 months asked to report hospitalization for a CV condition, including HF. This analysis included those ≥65 years who were hospitalized for HF (n=558). Data from REGARDS, medical charts, the American Hospital Associations annual survey database and Medicare’s Hospital Compare website were used. Number of standing medications at admission and discharge was examined. Polypharmacy was defined as taking at least 10 medications.
- Majority of older patients with HF took ≥5 medications (84% at admission and 95% at discharge) and approximately 50% took ≥10 medications (42% at admission and 55% at discharge). Patterns were similar for HFrEF and HFpEF patients.
- Median number of medications taken by those with polypharmacy at admission was 12 (IQR 11-14) and at discharge 12 (IQR 11-14). Median number of medications taken by those without polypharmacy at admission was 6 (IQR 4-8) and at discharge was 7 (IQR 6-9).
- Prevalence of polypharmacy at admission increased from 25% in 2003 to 2006 to 55% in 2011 to 2014 (Ptrend<0.0001) and at discharge it increased from 41% in 2003 to 2006 to 68% in 2011 to 2014 (Ptrend<0.0001). Increase in medication count over time was greatest for nonCV medications.
- Between hospital admission and discharge prevalence of polypharmacy increased from 42% to 55% (P<0.001). Loop diuretics, beta-blockers, aspirin and electrolyte supplements were the most commonly initiated medications between admission and discharge.
- Most common class of medications at both admission and discharge were nonCV medications.
- Number of nonCV medications increased at a faster rate than the number of either HF medications or non-HF CV medications at both admission and discharge.
- Beta-blockers were the most common HF medications; aspirin and statins the most common non-HF CV medications; and proton pump inhibitors, electrolyte supplements, and multivitamins the most common nonCV medications.
- Each additional comorbid condition increased the risk of polypharmacy at discharge by 13% (RR 1.13 per comorbid conditions, 95%CI: 1.08-1.19).
In this subset of participants from REGARDS which were older patients hospitalized for HF, prevalence of polypharmacy (at least 10 medications) was high. Prevalence of polypharmacy increased over time. And finally, the majority of medications prescribed to older patients with HF were nonCV medications. The authors conclude: ‘These findings support the need to develop strategies to mitigate the negative effects of polypharmacy among older adults with HF, potentially starting with formalized processes that can improve prescribing practices for nonCV medications’.