Published Online
on June 27, 2005

A more recent version of this article appeared on July 5, 2005

This Article Full Text (PDF) All Versions of this Article: 112/1/39    most recent CIRCULATIONAHA.104.527549v1 Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Masoudi, F. A. Articles by Krumholz, H. M. Search for Related Content PubMed PubMed Citation Articles by Masoudi, F. A. Articles by Krumholz, H. M. Pubmed/NCBI databases Compound via MeSH Substance via MeSH Medline Plus Health Information Heart Failure Hazardous Substances DB POTASSIUM SPIRONOLACTONE Related Collections Health policy and outcome research Congestive Other Treatment

Submitted on December 4, 2004
Revised on March 1, 2005
Accepted on March 28, 2005

Adoption of Spironolactone Therapy for Older Patients With Heart Failure and Left Ventricular Systolic Dysfunction in the United States, 1998-2001

Frederick A. Masoudi MD, MSPH^*, Cary P. Gross MD, Yongfei Wang MS, Saif S. Rathore MPH, Edward P. Havranek MD, JoAnne Micale Foody MD, and Harlan M. Krumholz MD, SM

From the Division of Cardiology, Department of Medicine, Denver Health Medical Center (F.A.M., E.P.H.); and the Division of Cardiology, Department of Medicine (F.A.M., E.P.H.), and the Division of Geriatric Medicine, Department of Medicine (F.A.M.), University of Colorado Health Sciences Center, Denver, Colo; the Colorado Foundation for Medical Care (F.A.M., E.P.H., H.M.K.), Aurora, Colo; the Colorado Health Outcomes Program (F.A.M.), Aurora, Colo; the Section of General Internal Medicine, Department of Medicine (C.P.G.); the Section of Cardiovascular Medicine, Department of Medicine (S.S.R., Y.W., J.M.F., H.M.K.), and the Section of Health Policy and Administration, Department of Epidemiology and Public Health (H.M.K.), Yale University School of Medicine, New Haven, Conn; the Center for Outcomes Research and Evaluation (H.M.K., C.G.), Yale-New Haven Hospital, New Haven, Conn; and the Section of Cardiology, Department of Medicine, West Haven Veteran’s Administration Medical Center (J.M.F.), West Haven, Conn.

^* To whom correspondence should be addressed. E-mail: fred.masoudi{at}uchsc.edu.

Background--Concerns have been raised about the appropriateness of spironolactone use in some patients with heart failure. We studied the adoption of spironolactone therapy after publication of the Randomized Aldactone Evaluation Study (RALES) in national cohorts of older patients hospitalized for heart failure.

Methods and Results--This is a study of serial cross-sectional samples of Medicare beneficiaries 65 years old discharged after hospitalization for the primary diagnosis of heart failure and with left ventricular systolic dysfunction. The first sample was discharged before (April 1998 to March 1999, n=9758) and the second sample after (July 2000 to June 2001, n=9468) publication of RALES in September 1999. We assessed spironolactone prescriptions at hospital discharge in patient groups defined by enrollment criteria for the trial. Using multivariable logistic regression, we identified factors independently associated with prescriptions not meeting these criteria. Spironolactone use increased >7-fold (3.0% to 21.3% P<0.0001) after RALES. Of patients meeting enrollment criteria, 24.1% received spironolactone, as compared with 17.4% of those not meeting the criteria. Of all prescriptions after RALES, 30.9% were provided to patients not meeting enrollment criteria. Spironolactone was prescribed to 22.8% of patients with a serum potassium value 5.0 mmol/L, to 14.1% with a serum creatinine value 2.5 mg/dL, and to 17.3% with severe renal dysfunction (estimated glomerular filtration rate <30 mL · min^-1 · 1.73 m^-2). In multivariable analyses, factors associated with prescriptions not meeting enrollment criteria included advanced age, noncardiovascular comorbidities, discharge to skilled nursing facilities, and care provided by physicians without board certification.

Conclusions--Spironolactone prescriptions increased markedly after the publication of RALES, and many treated patients were at risk for hyperkalemia. Simultaneously, many patients who might have benefited were not treated. These findings demonstrate the importance of balancing efforts to enhance use among appropriate patients and minimizing use in patients at risk for adverse events.

Key words: heart failure • aging • aldosterone antagonists • potassium

This article has been cited by other articles:

				O. J. Wang and H. M. Krumholz Clinical trial participation: are we studying the patients we are trying to treat? Eur J Heart Fail, November 1, 2009; 11(11): 1021 - 1022. [Full Text] [PDF]

				N. M. Albert, C. W. Yancy, L. Liang, X. Zhao, A. F. Hernandez, E. D. Peterson, C. P. Cannon, and G. C. Fonarow Use of Aldosterone Antagonists in Heart Failure JAMA, October 21, 2009; 302(15): 1658 - 1665. [Abstract] [Full Text] [PDF]

				J. A. Ezekowitz and F. A. McAlister Aldosterone blockade and left ventricular dysfunction: a systematic review of randomized clinical trials Eur. Heart J., February 2, 2009; 30(4): 469 - 477. [Abstract] [Full Text] [PDF]

				H. M. Krumholz, J. L. Anderson, B. L. Bachelder, F. M. Fesmire, S. D. Fihn, J. M. Foody, P. M. Ho, M. N. Kosiborod, F. A. Masoudi, and B. K. Nallamothu ACC/AHA 2008 Performance Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures for ST-Elevation and Non-ST-Elevation Myocardial Infarction) Developed in Collaboration With the American Academy of Family Physicians and American College of Emergency Physicians Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, Society for Cardiovascular Angiography and Interventions, and Society of Hospital Medicine J. Am. Coll. Cardiol., December 9, 2008; 52(24): 2046 - 2099. [Full Text] [PDF]

				WRITING COMMITTEE MEMBERS, H. M. Krumholz, J. L. Anderson, B. L. Bachelder, F. M. Fesmire, S. D. Fihn, J. M. Foody, P. M. Ho, M. N. Kosiborod, F. A. Masoudi, et al. ACC/AHA 2008 Performance Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures for ST-Elevation and Non-ST-Elevation Myocardial Infarction): Developed in Collaboration With the American Academy of Family Physicians and the American College of Emergency Physicians: Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, Society for Cardiovascular Angiography and Interventions, and Society of Hospital Medicine Circulation, December 9, 2008; 118(24): 2596 - 2648. [Full Text] [PDF]

				P. M. Ho, P. N. Peterson, and F. A. Masoudi Evaluating the Evidence: Is There a Rigid Hierarchy? Circulation, October 14, 2008; 118(16): 1675 - 1684. [Full Text] [PDF]

				F. A. McAlister Cardiac Resynchronization Therapy for Heart Failure: A Hammer in Search of Nails Circulation, August 26, 2008; 118(9): 901 - 903. [Full Text] [PDF]

				E. S. Holmboe, R. Lipner, and A. Greiner Assessing Quality of Care: Knowledge Matters JAMA, January 23, 2008; 299(3): 338 - 340. [Full Text] [PDF]

				F. A. Masoudi Measuring the Quality of Primary PCI for ST-Segment Elevation Myocardial Infarction: Time for Balance JAMA, December 19, 2007; 298(23): 2790 - 2791. [Full Text] [PDF]

				H. M. Krumholz and F. A. Masoudi The Year in Epidemiology, Health Services Research, and Outcomes Research J. Am. Coll. Cardiol., December 4, 2007; 50(23): 2254 - 2262. [Full Text] [PDF]

				G. H. Gislason, J. N. Rasmussen, S. Z. Abildstrom, T. K. Schramm, M. L. Hansen, P. Buch, R. Sorensen, F. Folke, N. Gadsboll, S. Rasmussen, et al. Persistent Use of Evidence-Based Pharmacotherapy in Heart Failure Is Associated With Improved Outcomes Circulation, August 14, 2007; 116(7): 737 - 744. [Abstract] [Full Text] [PDF]

				C. C Lang and D. M Mancini Non-cardiac comorbidities in chronic heart failure Heart, June 1, 2007; 93(6): 665 - 671. [Abstract] [Full Text] [PDF]

				H. M. Krumholz and F. A. Masoudi The Year in Epidemiology, Health Services Research, and Outcomes Research J. Am. Coll. Cardiol., November 7, 2006; 48(9): 1886 - 1895. [Full Text] [PDF]

				W. H. W. Tang, A. C. Parameswaran, A. P. Maroo, and G. S. Francis Aldosterone Receptor Antagonists in the Medical Management of Chronic Heart Failure Mayo Clin. Proc., December 1, 2005; 80(12): 1623 - 1630. [Abstract] [PDF]

				F. A. Masoudi, C. A. Baillie, Y. Wang, W. D. Bradford, J. F. Steiner, E. P. Havranek, J. M. Foody, and H. M. Krumholz The Complexity and Cost of Drug Regimens of Older Patients Hospitalized With Heart Failure in the United States, 1998-2001 Arch Intern Med, October 10, 2005; 165(18): 2069 - 2076. [Abstract] [Full Text] [PDF]

				How Is Spironolactone Being Used for Heart Failure in Practice? Journal Watch Cardiology, September 9, 2005; 2005(909): 1 - 1. [Full Text]