Hospital Pharmacy - November 2017 - 701

701

Patterson et al
Table 2. Aldosterone Antagonist Use (N = 346).
Received an aldosterone
antagonist, n (%)

121 (35.0)

Did not receive an
aldosterone antagonist, n (%)

225 (65.2)

Consistent with guidelines
Inconsistent with guidelines
Hyperkalemia
Renal dysfunction
Both

116 (95.9)
5 (4.1)
3 (2.4)
2 (1.7)
0 (0)

Consistent with guidelines
Hyperkalemia
Renal Dysfunction
Both
Inconsistent with guidelines

55 (24.4)
6 (2.7)
45 (20.0)
4 (1.8)
170 (75.6)

Table 3. Readmission Rates.
Outcomes

Received an aldosterone
antagonist (n = 121)

Did not receive an aldosterone
antagonist (n = 225)

Total

0-30 days*
0-90 days†

17 (27.9)
32 (29.6)

44 (72.1)
76 (70.4)

61 (17.6)
108 (31.3)

*P = .204, Pearson's chi-square test.
†
P = .179, Pearson's chi-square test.

guidelines. Therapy was considered inconsistent with the
guidelines in 3 patients with hyperkalemia and 2 patients
with renal dysfunction (Table 2). The remaining 65% of
patients were not provided an aldosterone antagonist at discharge, yet only 55 of these 225 patients actually had at least
1 contraindication to therapy. Of these patients, 6 had hyperkalemia alone, 4 had hyperkalemia and renal dysfunction,
and 45 patients had renal dysfunction. In addition, of those
not receiving an aldosterone antagonist (n = 225), 170
(75.6%) were eligible for aldosterone antagonist therapy
with no contraindication present.
Sixty-one patients (17.6%) were readmitted to the academic medical center within 30 days. Seventeen (27.9%) of
these patients received an aldosterone antagonist at discharge
compared with 44 (72.1%) who did not receive an aldosterone antagonist (P = .24). Readmission within 90 days
occurred for 108 patients (31.2%), with 32 patients (29.6%)
in the aldosterone therapy group compared with 76 patients
(70.4%) in the group who did not receive an aldosterone
antagonist (P = .19) (Table 3). Of the 5 patients who received
an aldosterone antagonist and had a contraindication to therapy, 2 patients were readmitted. One patient had hyperkalemia (30 days readmit), and the other patient had renal failure
(readmit 90 days). Of the 170 patients, who did not receive
an aldosterone antagonist without contraindication to therapy, 31 (18.2%) patients were readmitted within 30 days and
52 (30.6%) were readmitted within 90 days.

Discussion
Despite the current ACCF/AHA guideline recommendations
and recent literature, this study found that only 35% patients
received an aldosterone antagonist at discharge. Our study
adds to the growing body of literature regarding underuse of
aldosterone antagonists. It is our hope that this investigation

will encourage hospital-based pharmacists and other health
care professionals to be more vigilant regarding the use of
this valuable class of agents for reduced EF patients. This is
the first study that observed the use of aldosterone antagonists in a patient population that consisted of greater than
85% African Americans. Although there were previous concerns regarding hyperkalemia from the RALES study, only 5
(4.1%) patients received an aldosterone antagonist when a
contraindication existed. It is important to note that only
62% of HF patients were discharged on standard therapy of
beta-blocker and ACE inhibitor or ARB, and this finding
could reflect why there was underutilization of aldosterone
antagonists in this study. Patients may not have been on standard therapy due to hypotension or other contraindications to
therapy; however, this study did not observe these findings.
We note that during the time period of our study, the 2009
Guidelines8 applied; with the 2013 Guidelines,5 the following statement is included: Aldosterone receptor antagonists
are recommended to reduce morbidity and mortality following an acute myocardial infarction in patients who have a
left ventricular ejection fraction (LVEF) of 40% or less who
develop symptoms of HF or who have a history of diabetes
mellitus, unless contraindicated. Subsequent studies examining aldosterone antagonist use should address these
comorbidities.9
In a retrospective study, Chamsi-Pasha et al10 found that
aldosterone antagonists continue to be underutilized in
patients admitted with acute decompensated HF. The most
frequent reason for in-hospital discontinuation of aldosterone antagonists was increased serum creatinine and worsening of kidney function. The authors pointed out the
importance of careful follow-up after aldosterone antagonist therapy initiation. Rossignol et al11 reported that in
patients with HF receiving optimal treatment, worsening
renal function and hyperkalemia were more common after



Table of Contents for the Digital Edition of Hospital Pharmacy - November 2017

AKD—The Time Between AKI and CKD: What Is the Role of the Pharmacist?
Letter to the Editor
Antithrombotic Therapy Post Endovascular Stenting for Superior Vena Cava Syndrome
Pharmaceutical Pipeline Update
Janus Kinase Inhibitors for the Treatment of Rheumatoid Arthritis
Formulary Drug Reviews
Etelcalcetide
Treatment of Hypertriglyceridemia-Induced Acute Pancreatitis With Insulin, Heparin, and Gemfibrozil: A Case Series
Evaluation of Antimicrobial Stewardship–Related Alerts Using a Clinical Decision Support System
Compatibility, Stability, and Efficacy of Vancomycin Combined With Gentamicin or Ethanol in Sodium Citrate as a Catheter Lock Solution
Development of Institutional Guidelines for Management of Gram-Negative Bloodstream Infections: Incorporating Local Evidence
Underutilization of Aldosterone Antagonists in Heart Failure
Stability of Procainamide Injection in Clear Glass Vials and Polyvinyl Chloride Bags
Development of a Local Health-System Pharmacy Resident Society
Challenges and Solutions to New Manager Onboarding
Hospital Pharmacy - November 2017 - 649
Hospital Pharmacy - November 2017 - 650
Hospital Pharmacy - November 2017 - 651
Hospital Pharmacy - November 2017 - 652
Hospital Pharmacy - November 2017 - 653
Hospital Pharmacy - November 2017 - 654
Hospital Pharmacy - November 2017 - 655
Hospital Pharmacy - November 2017 - 656
Hospital Pharmacy - November 2017 - 657
Hospital Pharmacy - November 2017 - 658
Hospital Pharmacy - November 2017 - 659
Hospital Pharmacy - November 2017 - 660
Hospital Pharmacy - November 2017 - AKD—The Time Between AKI and CKD: What Is the Role of the Pharmacist?
Hospital Pharmacy - November 2017 - 662
Hospital Pharmacy - November 2017 - Letter to the Editor
Hospital Pharmacy - November 2017 - Pharmaceutical Pipeline Update
Hospital Pharmacy - November 2017 - Janus Kinase Inhibitors for the Treatment of Rheumatoid Arthritis
Hospital Pharmacy - November 2017 - Formulary Drug Reviews
Hospital Pharmacy - November 2017 - Etelcalcetide
Hospital Pharmacy - November 2017 - 668
Hospital Pharmacy - November 2017 - 669
Hospital Pharmacy - November 2017 - 670
Hospital Pharmacy - November 2017 - 671
Hospital Pharmacy - November 2017 - 672
Hospital Pharmacy - November 2017 - Treatment of Hypertriglyceridemia-Induced Acute Pancreatitis With Insulin, Heparin, and Gemfibrozil: A Case Series
Hospital Pharmacy - November 2017 - 674
Hospital Pharmacy - November 2017 - 675
Hospital Pharmacy - November 2017 - 676
Hospital Pharmacy - November 2017 - Evaluation of Antimicrobial Stewardship–Related Alerts Using a Clinical Decision Support System
Hospital Pharmacy - November 2017 - 678
Hospital Pharmacy - November 2017 - 679
Hospital Pharmacy - November 2017 - 680
Hospital Pharmacy - November 2017 - 681
Hospital Pharmacy - November 2017 - 682
Hospital Pharmacy - November 2017 - Compatibility, Stability, and Efficacy of Vancomycin Combined With Gentamicin or Ethanol in Sodium Citrate as a Catheter Lock Solution
Hospital Pharmacy - November 2017 - 684
Hospital Pharmacy - November 2017 - 685
Hospital Pharmacy - November 2017 - 686
Hospital Pharmacy - November 2017 - 687
Hospital Pharmacy - November 2017 - 688
Hospital Pharmacy - November 2017 - Development of Institutional Guidelines for Management of Gram-Negative Bloodstream Infections: Incorporating Local Evidence
Hospital Pharmacy - November 2017 - 690
Hospital Pharmacy - November 2017 - 691
Hospital Pharmacy - November 2017 - 692
Hospital Pharmacy - November 2017 - 693
Hospital Pharmacy - November 2017 - 694
Hospital Pharmacy - November 2017 - 695
Hospital Pharmacy - November 2017 - Underutilization of Aldosterone Antagonists in Heart Failure
Hospital Pharmacy - November 2017 - 697
Hospital Pharmacy - November 2017 - 698
Hospital Pharmacy - November 2017 - 699
Hospital Pharmacy - November 2017 - 700
Hospital Pharmacy - November 2017 - 701
Hospital Pharmacy - November 2017 - Stability of Procainamide Injection in Clear Glass Vials and Polyvinyl Chloride Bags
Hospital Pharmacy - November 2017 - 703
Hospital Pharmacy - November 2017 - 704
Hospital Pharmacy - November 2017 - 705
Hospital Pharmacy - November 2017 - 706
Hospital Pharmacy - November 2017 - Development of a Local Health-System Pharmacy Resident Society
Hospital Pharmacy - November 2017 - 708
Hospital Pharmacy - November 2017 - 709
Hospital Pharmacy - November 2017 - Challenges and Solutions to New Manager Onboarding
Hospital Pharmacy - November 2017 - 711
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