Clincial trials have established the incremental benefits of aldosterone antagonist therapy in patients with failure (HF) and reduced left ventricular ejection fraction (LVEF), such that aldosterone antagonists were designated as class I, “useful and recommended,” within the American College of Cardiology/American Heart Association (ACC/AHA) Chronic HF Guidelines. Because aldosterone antagonists can cause hyperkalemia, guidelines promote safety by specifying that prior to use, serum creatinine levels should be 2.5 mg/dL or less in men and 2.0 mg/dL or less in women, and serum potassium levels should be less than 5.0 mEq/L.1 Adoption of aldosterone antagonists in HF has been mixed; early community studies in Canada and the United States found modest uptake but also increased use in individuals with contraindications and increased admissions for hyperkalemia.The Get With The Guidelines–HF (GWTG-HF) program is a national quality improvement program designed to promote adherence to guideline- based recommendations. It is unknown whether participation in a hospital-based quality improvement program may lead to greater frequency of use of aldosterone antagonist therapy for appropriate indications as well as lower use in situations of increased risk. Therefore, the purpose of this study was to examine contemporary aldosterone antagonist use among hospitalized patients with HF, temporal trends in use, and appropriateness of use.

This is, to our knowledge, the first report of aldosterone antagonist use and appropriateness since the 2005 ACC/ AHA guideline statements emphasized both appropriate indications and safety precautions. This study had 4 main findings:

1. only one-third of patients meeting current guideline criteria for aldosterone antagonist therapy and without documented contraindications were treated.

2.  prescription of aldosterone antagonist at discharge varies widely among clinicians.

3. aldosterone antagonist use for appropriate indications is less common among patients who are elderly, white, have a lower systolic blood pressure, do not have an implantable cardioverter defibrillator or pacemaker, do not have a history of alcohol use or depression, and have a history of renal insufficiency.

4. in contrast to prior reports, rates of inappropriateuse are infrequent; only 0.5% of patients received therapy when they had a documented contraindication, and 2.7% received therapy when they had a higher than recommended creatinine level. Aldosterone antagonist therapy increased modestly in the United States, from the first half of 2005 to the second half of 2007 among adult patients hospitalized with HF.

In conclusion, the results of our study demonstrate that Aldosterone antagonist usage in eligible patients with HF increased only modestly from 2005 through 2007 and remained at less than 35% penetration. Importantly, inappropriate use was low. These data confirm that in the context of a hospital-based performance improvement program, aldosterone antagonist therapy can be used according to guidelines with little inappropriate use. Given the substantial morbidity and mortality risk faced by patients hospitalized with HF and the established efficacy of aldosterone antagonist prescription in HF, a stronger uptake of aldosterone antagonist therapy indicated by evidence-based guidelines may be warranted.

summarized by permission from the original article JAMA 2009; 302(15):1658-1665 (doi:10.1001/jama.2009.1493)