However, only about one-third of patients have good adherence, according to findings published in JACC: Heart Failure.
"The main recommendation for physicians is to start eligible patients on this guideline-recommended therapy while they are still hospitalized. Patients can't benefit from drugs that aren't prescribed to them, and very few end up being started on sacubitril/valsartan in the outpatient setting after they leave the hospital," said senior author Dr. Emily O'Brien of Duke University School of Medicine in Durham, North Carolina.
"Starting them on therapy before discharge and providing education about the importance of adherence when they go home gives people the best chance of staying on treatment and reducing their risk of hospitalization and death," she told Reuters Health by email.
The researchers retrospectively reviewed three years of records from 897 patients in the Get With the Guidelines-Heart Failure registry linked to Medicare. The patients included were discharged with sacubitril/valsartan prescriptions. The researchers measured adherence through each patient's recorded prescription fills, looking at the proportion of days covered.
Adherence was low, Dr. O'Brien said. Only 295 patients, or 32.9%, had a proportion of days covered of 80% or more.
But those who did adhere appeared to have benefited from a "remarkable" degree of risk reduction, the researchers write. One year after discharge, adherence was associated with a 47% reduction in all-cause mortality (hazard ratio, 0.53; 95% confidence interval, 0.38 to 0.74) and a 31% reduction in all-cause readmission (HR, 0.69; [95% CI, 0.56 to 0.86).
The existence of a link between adherence and patient outcomes may come as little surprise, given the evidence behind the drug. Sacubitril/valsartan, sold by Novartis under the brand name Entresto, is a neprilysin inhibitor combined with an angiotensin-receptor blocker that has demonstrated efficacy and outperformed other treatments in clinical trials.
The PARADIGM-HF trial found a 20% reduction in risk of death or hospitalization among ambulatory patients with heart failure with reduced ejection fraction, Dr. Ankeet Bhatt of Brigham and Women's Hospital, Harvard Medical School, in Boston, notes in a linked editorial.
"For the medical system as a whole, I think the real keys are we need to start thinking beyond implementation science as being only about the initial prescription of therapy. It really needs to be about how to promote prescription of evidence-based therapies, but then also promote long-term adherence," Dr. Bhatt told Reuters Health by phone.
He outlined three strategies for moving toward large-scale use of evidence-based therapies like sacubitril/valsartan. One, measure adherence more effectively. Two, design implementation-science interventions focused on the initial prescription and sustained use of therapies. And three, design what he calls "adherence-informed therapeutics," or a user-friendly system of therapy delivery that is easy for patients.
"We're starting to see that with a whole host of novel therapeutics in cardiovascular disease and elsewhere, so I think that could be a wave of the future," Dr. Bhatt said.
SOURCE: https://bit.ly/3ACedZa and https://bit.ly/3v6gWJn JACC: Heart Failure, online September 8, 2021.
By Rob Goodier
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