J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Original Article

Volume 5, Number 3, June 2013, pages 194-204

Trends in the Medical Management of Patients With Heart Failure

**Table 1.** Demographic and Clinical Characteristics of Patients Hospitalized With Acute Heart Failure
	Total Population	1995 Cohort	2004 Cohort
Data are given as percentages or means unless otherwise noted.
Age (mean, years)	76.2	75.7	76.2
Age group (years) (%)
< 65	15.6	14.3	16.7
65 - 74	21.5	26.9	20.8
75 - 84	37.1	37.5	34.1
≥ 85	25.7	21.4	28.4
Male	43.9	42.9	46.9
Caucasian	93.8	96.8	92.3
Incident event	29.0	26.1	36.4
Length of hospital stay (days)	6.1	7.4	6.1
Physiologic Factors
Cholesterol (mg/dL)	163.1	178.9	149.9
Systolic blood pressure (mmHg)	142.9	146.3	140.6
Diastolic blood pressure (mmHg)	74.7	79.1	72.5
eGFR (mL/min/1.73 m2)	52.7	54.1	51.8
Glucose (mg/dL)	160.6	169.5	152.9
Medical History (%)
Anemia	24.6	21.9	26.7
Coronary heart disease	56.0	57.0	55.7
Chronic lung disease	35.9	35.5	35.7
Diabetes	39.0	39.7	39.3
Hypertension	68.7	62.3	72.8
Peripheral vascular disease	19.7	20.2	21.0
Renal failure	25.9	21.5	31.4
Stroke	13.2	14.3	11.5
Presenting Symptoms (%)
Angina/chest pain	31.2	31.2	29.9
Dyspnea/shortness of breath	93.4	96.5	92.2
Edema/swelling	70.3	63.8	72.7
Nausea/vomiting	16.0	14.2	17.1
Orthopnea	35.4	29.2	38.4
Weakness	25.1	24.9	23.8

Table 1. Demographic and Clinical Characteristics of Patients Hospitalized With Acute Heart Failure

Total Population

1995 Cohort

2004 Cohort

(n = 9,748)

(n = 1,949)

(n = 2,469)

Data are given as percentages or means unless otherwise noted.

Age (mean, years)

76.2

75.7

76.2

Age group (years) (%)

< 65

15.6

14.3

16.7

65 - 74

21.5

26.9

20.8

75 - 84

37.1

37.5

34.1

≥ 85

25.7

21.4

28.4

Male

43.9

42.9

46.9

Caucasian

93.8

96.8

92.3

Incident event

29.0

26.1

36.4

Length of hospital stay (days)

6.1

7.4

6.1

Physiologic Factors

Cholesterol (mg/dL)

163.1

178.9

149.9

Systolic blood pressure (mmHg)

142.9

146.3

140.6

Diastolic blood pressure (mmHg)

74.7

79.1

72.5

eGFR (mL/min/1.73 m2)

52.7

54.1

51.8

Glucose (mg/dL)

160.6

169.5

152.9

Medical History (%)

Anemia

24.6

21.9

26.7

Coronary heart disease

56.0

57.0

55.7

Chronic lung disease

35.9

35.5

35.7

Diabetes

39.0

39.7

39.3

Hypertension

68.7

62.3

72.8

Peripheral vascular disease

19.7

20.2

21.0

Renal failure

25.9

21.5

31.4

Stroke

13.2

14.3

11.5

Presenting Symptoms (%)

Angina/chest pain

31.2

29.9

Dyspnea/shortness of breath

93.4

96.5

92.2

Edema/swelling

70.3

63.8

72.7

Nausea/vomiting

16.0

14.2

17.1

Orthopnea

35.4

29.2

38.4

Weakness

25.1

24.9

23.8

**Table 2.** Trends in Selected Medication Use in all Patients Hospitalized With Acute Heart Failure
	ACE-I/ ARBs	Aldosterone Antagonists	Aspirin	Beta Blockers	Calcium Channel Blockers	Digoxin	Diuretics	Nitrates	Statins
Pre-hospital data excludes incident cases of acute HF; Hospital discharge data excludes hospital decedents; ACE-I/ARBs = angiotensin converting enzyme inhibitors or angiotensin receptor blockers.
Pre-Hospital (%)
1995	43.7	na	28.0	20.1	35.5	49.9	82.9	46.4	6.0
2000	48.2	na	39.6	44.9	27.2	41.1	81.1	38	20.0
2002	55.3	8.0	43.4	55.3	24.6	37.0	84.0	31.6	33.4
2004	55.2	9.4	48.8	67.9	24.6	29.7	83.4	29.5	46.3
In-Hospital (%)
1995	50.4	na	38.9	26.2	40.2	55.0	97.9	67.9	5.8
2000	55.9	na	56.4	51.8	33.0	47.2	97.7	62.5	21.0
2002	58.6	9.3	59.0	62.5	29.8	41.2	96.6	53.0	32.8
2004	60.7	11.3	63.1	73.7	29.7	33.3	96.4	47.1	44.9
Discharge (%)
1995	46.5	na	35.0	22.6	32.8	50.9	82.5	45.6	5.4
2000	51.9	na	47.6	46.8	26.2	42.6	82.3	35.6	20.6
2002	54.2	7.7	48.6	56.5	22.9	36.7	80.1	27.4	30.9
2004	54.8	9.1	51.0	67.5	22.5	29.1	81.7	24.5	43.4

Table 2. Trends in Selected Medication Use in all Patients Hospitalized With Acute Heart Failure

ACE-I/ ARBs

Aldosterone Antagonists

Aspirin

Beta Blockers

Calcium Channel Blockers

Digoxin

Diuretics

Nitrates

Statins

Pre-hospital data excludes incident cases of acute HF; Hospital discharge data excludes hospital decedents; ACE-I/ARBs = angiotensin converting enzyme inhibitors or angiotensin receptor blockers.

Pre-Hospital (%)

1995

43.7

28.0

20.1

35.5

49.9

82.9

46.4

6.0

2000

48.2

39.6

44.9

27.2

41.1

81.1

20.0

2002

55.3

8.0

43.4

55.3

24.6

37.0

84.0

31.6

33.4

2004

55.2

9.4

48.8

67.9

24.6

29.7

83.4

29.5

46.3

In-Hospital (%)

1995

50.4

38.9

26.2

40.2

55.0

97.9

67.9

5.8

2000

55.9

56.4

51.8

33.0

47.2

97.7

62.5

21.0

2002

58.6

9.3

59.0

62.5

29.8

41.2

96.6

53.0

32.8

2004

60.7

11.3

63.1

73.7

29.7

33.3

96.4

47.1

44.9

Discharge (%)

1995

46.5

35.0

22.6

32.8

50.9

82.5

45.6

5.4

2000

51.9

47.6

46.8

26.2

42.6

82.3

35.6

20.6

2002

54.2

7.7

48.6

56.5

22.9

36.7

80.1

27.4

30.9

2004

54.8

9.1

51.0

67.5

22.5

29.1

81.7

24.5

43.4

**Table 3.** Trends in Medication Use in Patients With HFrEF
	ACE-I/ ARBs	Aldosterone Antagonists	Aspirin	Beta Blockers	Calcium Channel Blockers	Digoxin	Diuretics	Nitrates	Statins
Pre-hospital data excludes incident cases of acute HF; Hospital discharge data excludes hospital decedents; ACE-I/ARBs = angiotensin converting enzyme inhibitors or angiotensin receptor blockers
Pre-Hospital (%)
1995	44.4	N/A	28.0	19.6	34.9	46.6	76.7	43.4	6.4
2000	52.6	N/A	39.1	44.7	21.7	44.3	78.0	40.1	28.4
2002	64.6	5.7	43.4	57.1	16.0	42.9	82.0	29.4	36.6
2004	59.0	9.5	50.2	70.0	20.2	32.6	77.3	30.0	52.0
In-Hospital (%)
1995	67.3	N/A	52.5	31.2	38.6	64.8	97.8	72.8	5.9
2000	74.3	N/A	63.9	57.1	28.4	65.3	98.6	67.4	27.8
2002	79.2	10.8	68.7	72.4	23.8	57.7	96.7	53.5	37.3
2004	73.0	16.4	73.0	82.4	24.3	46.7	96.6	52.7	49.5
Discharge (%)
1995	59.6	N/A	42.4	21.9	25.2	58.9	80.8	45.7	4.6
2000	69.8	N/A	53.4	48.5	18.3	60.2	87.0	34.4	26.8
2002	72.3	9.5	55.0	66.1	15.0	52.2	83.4	26.1	33.5
2004	66.0	14.7	58.2	74.4	14.0	40.5	79.5	28.7	46.8

Table 3. Trends in Medication Use in Patients With HFrEF

ACE-I/ ARBs

Aldosterone Antagonists

Aspirin

Beta Blockers

Calcium Channel Blockers

Digoxin

Diuretics

Nitrates

Statins

Pre-hospital data excludes incident cases of acute HF; Hospital discharge data excludes hospital decedents; ACE-I/ARBs = angiotensin converting enzyme inhibitors or angiotensin receptor blockers

Pre-Hospital (%)

1995

44.4

N/A

28.0

19.6

34.9

46.6

76.7

43.4

6.4

2000

52.6

N/A

39.1

44.7

21.7

44.3

78.0

40.1

28.4

2002

64.6

5.7

43.4

57.1

16.0

42.9

82.0

29.4

36.6

2004

59.0

9.5

50.2

70.0

20.2

32.6

77.3

30.0

52.0

In-Hospital (%)

1995

67.3

N/A

52.5

31.2

38.6

64.8

97.8

72.8

5.9

2000

74.3

N/A

63.9

57.1

28.4

65.3

98.6

67.4

27.8

2002

79.2

10.8

68.7

72.4

23.8

57.7

96.7

53.5

37.3

2004

73.0

16.4

73.0

82.4

24.3

46.7

96.6

52.7

49.5

Discharge (%)

1995

59.6

N/A

42.4

21.9

25.2

58.9

80.8

45.7

4.6

2000

69.8

N/A

53.4

48.5

18.3

60.2

87.0

34.4

26.8

2002

72.3

9.5

55.0

66.1

15.0

52.2

83.4

26.1

33.5

2004

66.0

14.7

58.2

74.4

14.0

40.5

79.5

28.7

46.8

**Table 4.** Trends in Medication Use in Patients With HFpEF
	ACE-I/ ARBs	Aldosterone Antagonists	Aspirin	Beta Blockers	Calcium Channel Blockers	Digoxin	Diuretics	Nitrates	Statins
Pre-hospital data excludes incident cases of acute HF; Hospital discharge data excludes hospital decedents; ACE-I/ARBs = angiotensin converting enzyme inhibitors or angiotensin receptor blockers.
Pre-Hospital (%)
1995	34.7	N/A	22.8	27.7	49.5	33.7	78.2	39.6	8.9
2000	38.2	N/A	40.8	41.2	39.0	29.2	78.7	27.0	19.5
2002	46.3	6.4	37.2	57.9	32.6	25.6	83.2	25.9	32.9
2004	52.3	6.6	45.6	62.0	33.8	22.3	81.5	21.6	40.8
In-Hospital (%)
1995	45.0	N/A	45.0	29.8	56.7	45.0	98.8	68.4	5.3
2000	49.1	N/A	57.6	51.6	45.1	35.3	97.8	59.8	20.3
2002	48.2	7.5	59.4	62.4	37.6	29.6	97.6	51.1	28.1
2004	56.8	5.6	61.5	70.5	40.6	22.7	97.7	42.4	40.3
Discharge (%)
1995	36.7	N/A	38.0	25.3	43.0	39.9	76.0	39.2	5.1
2000	43.5	N/A	47.8	44.9	35.2	27.2	74.0	25.3	20.6
2002	41.7	6.4	46.2	54.9	28.1	23.7	76.9	22.0	25.9
2004	46.6	3.7	46.2	62.8	31.8	15.8	77.1	16.6	38.4

Table 4. Trends in Medication Use in Patients With HFpEF

ACE-I/ ARBs

Aldosterone Antagonists

Aspirin

Beta Blockers

Calcium Channel Blockers

Digoxin

Diuretics

Nitrates

Statins

Pre-hospital data excludes incident cases of acute HF; Hospital discharge data excludes hospital decedents; ACE-I/ARBs = angiotensin converting enzyme inhibitors or angiotensin receptor blockers.

Pre-Hospital (%)

1995

34.7

N/A

22.8

27.7

49.5

33.7

78.2

39.6

8.9

2000

38.2

N/A

40.8

41.2

39.0

29.2

78.7

27.0

19.5

2002

46.3

6.4

37.2

57.9

32.6

25.6

83.2

25.9

32.9

2004

52.3

6.6

45.6

62.0

33.8

22.3

81.5

21.6

40.8

In-Hospital (%)

1995

45.0

N/A

45.0

29.8

56.7

45.0

98.8

68.4

5.3

2000

49.1

N/A

57.6

51.6

45.1

35.3

97.8

59.8

20.3

2002

48.2

7.5

59.4

62.4

37.6

29.6

97.6

51.1

28.1

2004

56.8

5.6

61.5

70.5

40.6

22.7

97.7

42.4

40.3

Discharge (%)

1995

36.7

N/A

38.0

25.3

43.0

39.9

76.0

39.2

5.1

2000

43.5

N/A

47.8

44.9

35.2

27.2

74.0

25.3

20.6

2002

41.7

6.4

46.2

54.9

28.1

23.7

76.9

22.0

25.9

2004

46.6

3.7

46.2

62.8

31.8

15.8

77.1

16.6

38.4

**Table 5.** Changing Trends in Hospital Discharge Medication Use in Patients With Acute Heart Failure
Medication	Total Population	Preserved Ejection Fraction Findings	Reduced Ejection Fraction Findings
*95% Confidence Intervals.
ACE inhibitors/ARB’s	1.26 (1.10, 1.43)*	1.42 (1.25, 1.62)*	1.54 (1.35, 1.76)*	1.34 (0.90, 2.00)*	1.27 (0.86, 1.88)*	1.63 (1.10, 2.42)*	1.65 (1.19, 2.28)*	1.93 (1.39, 2.69)*	1.49 (1.07, 2.07)*
Aspirin	1.81 (1.59, 2.07)	1.90 (1.66, 2.17)	2.13 (1.86, 2.45)	1.56 (1.04, 2.33)	1.50 (1.01, 2.22)	1.52 (1.02, 2.25)	1.75 (1.29, 2.39)	1.91 (1.39, 2.60)	2.33 (1.70, 3.20)
Beta blockers	3.51 (3.03, 4.06)	5.46 (4.71, 6.33)	8.92 (7.64, 10.40)	2.85 (1.84, 4.43)	4.52 (2.93, 6.96)	6.52 (4.20, 10.14)	4.15 (2.91, 5.91)	9.55 (6.62, 13.78)	14.25 (9.74, 20.83)
Calcium channel blockers	0.70 (0.61, 0.80)	0.54 (0.47, 0.63)	0.53 (0.45, 0.61)	0.69 (0.46, 1.03)	0.45 (0.30, 0.67)	0.53 (0.36, 0.80)	0.65 (0.44, 0.94)	0.46 (0.31, 0.68)	0.44 (0.29, 0.66)
Digoxin	0.71 (0.63, 0.81)	0.58 (0.51, 0.65)	0.42 (0.37, 0.49)	0.63 (0.42, 0.95)	0.53 (0.35, 0.79)	0.34 (0.22, 0.51)	0.98 (0.72, 1.34)	0.69 (0.51, 0.95)	0.47 (0.34, 0.64)
Diuretics	0.87 (0.73, 1.03)	0.76 (0.64, 0.90)	0.97 (0.81, 1.16)	0.76 (0.48, 1.22)	0.93 (0.59, 1.48)	1.03 (0.64, 1.64)	1.41 (0.93, 2.14)	1.00 (0.67, 1.50)	0.82 (0.55, 1.21)
Lipid lowering medications	5.37 (4.24, 6.80)	10.02 (7.94, 12.64)	18.52 (14.65, 23.41)	6.17 (2.81, 13.53)	8.40 (3.88, 18.21)	17.01 (7.83, 36.96)	8.26 (4.56, 14.95)	12.54 (6.94, 22.66)	24.61 (13.59, 44.57)
Nitrates	0.62 (0.54, 0.71)	0.40 (0.35, 0.47)	0.36 (0.31, 0.42)	0.42 (0.27, 0.66)	0.36 (0.23, 0.55)	0.23 (0.15, 0.36)	0.57 (0.41, 0.80)	0.36 (0.26, 0.51)	0.41 (0.29, 0.59)

Table 5. Changing Trends in Hospital Discharge Medication Use in Patients With Acute Heart Failure

Medication

Total Population

Preserved Ejection Fraction Findings

Reduced Ejection Fraction Findings

2000

2002

2004

2000

2002

2004

2000

2002

2004

(n = 2,587)

(n = 2,743)

(n = 2,469)

(n = 448)

(n = 591)

(n = 576)

(n = 490)

(n = 518)

(n = 493)

O.R.

*95% Confidence Intervals.

ACE inhibitors/ARB’s

1.26
(1.10, 1.43)*

1.42
(1.25, 1.62)*

1.54
(1.35, 1.76)*

1.34
(0.90, 2.00)*

1.27
(0.86, 1.88)*

1.63
(1.10, 2.42)*

1.65
(1.19, 2.28)*

1.93
(1.39, 2.69)*

1.49
(1.07, 2.07)*

Aspirin

1.81
(1.59, 2.07)

1.90
(1.66, 2.17)

2.13
(1.86, 2.45)

1.56
(1.04, 2.33)

1.50
(1.01, 2.22)

1.52
(1.02, 2.25)

1.75
(1.29, 2.39)

1.91
(1.39, 2.60)

2.33
(1.70, 3.20)

Beta blockers

3.51
(3.03, 4.06)

5.46
(4.71, 6.33)

8.92
(7.64, 10.40)

2.85
(1.84, 4.43)

4.52
(2.93, 6.96)

6.52
(4.20, 10.14)

4.15
(2.91, 5.91)

9.55
(6.62, 13.78)

14.25
(9.74, 20.83)

Calcium channel blockers

0.70
(0.61, 0.80)

0.54
(0.47, 0.63)

0.53
(0.45, 0.61)

0.69
(0.46, 1.03)

0.45
(0.30, 0.67)

0.53
(0.36, 0.80)

0.65
(0.44, 0.94)

0.46
(0.31, 0.68)

0.44
(0.29, 0.66)

Digoxin

0.71
(0.63, 0.81)

0.58
(0.51, 0.65)

0.42
(0.37, 0.49)

0.63
(0.42, 0.95)

0.53
(0.35, 0.79)

0.34
(0.22, 0.51)

0.98
(0.72, 1.34)

0.69
(0.51, 0.95)

0.47
(0.34, 0.64)

Diuretics

0.87
(0.73, 1.03)

0.76
(0.64, 0.90)

0.97
(0.81, 1.16)

0.76
(0.48, 1.22)

0.93
(0.59, 1.48)

1.03
(0.64, 1.64)

1.41
(0.93, 2.14)

1.00
(0.67, 1.50)

0.82
(0.55, 1.21)

Lipid lowering medications

5.37
(4.24, 6.80)

10.02
(7.94, 12.64)

18.52
(14.65, 23.41)

6.17
(2.81, 13.53)

8.40
(3.88, 18.21)

17.01
(7.83, 36.96)

8.26
(4.56, 14.95)

12.54
(6.94, 22.66)

24.61
(13.59, 44.57)

Nitrates

0.62
(0.54, 0.71)

0.40
(0.35, 0.47)

0.36
(0.31, 0.42)

0.42
(0.27, 0.66)

0.36
(0.23, 0.55)

0.23
(0.15, 0.36)

0.57
(0.41, 0.80)

0.36
(0.26, 0.51)

0.41
(0.29, 0.59)