Patterns of cardioprotective medication prescription in incident hemodialysis patients
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BACKGROUND: There is a lack of evidence to guide medical decision making regarding cardiac medication therapy in hemodialysis (HD) patients. The aim of the study was to describe cardioprotective medication prescription patterns in incident HD patients with left ventricular dysfunction (LVDys) and patients' post-acute coronary syndrome. DESIGN: Incident HD patients between January 2002 and December 2004 were included and followed until 2007 or death. Data extraction was retrospective by means of electronic chart review and from a local dialysis database. RESULTS: A total of 272 patients were included for analysis; 104 of them (38%) had LVDys. Patients with severe LVDys (EF < 40%) were more likely to be prescribed angiotensin converting enzyme inhibitors (55.8 vs. 39.1%, P = 0.051), beta-blockers (81.4 vs. 62.4%, P = 0.018), statins (60.5 vs 38.3%, P = 0.009), ASA (37.2 vs 21%, P = 0.27) and clopidogrel (16.3 vs. 3%, P = 0.001). Sixty-five (24%) suffered an acute coronary syndrome (ACS) and were prescribed ACE inhibitors (57 vs. 38%, P = 0.006), beta-blockers (85 vs. 59%, P = NS), short-acting nitrates (14.0 vs. 2.0%, P < 0.0001), statin (65 vs. 36%, P < 0.0001), clopidogrel (25 vs. 2%, P < 0.0001) and ASA (60 vs. 18%, P < 0.0001). Using multiple logistic regression, LVDys was associated with mortality (OR 1.79, CI 100-3.21, P = 0.05), beta-blockers conferred a mortality benefit (OR 0.50, CI 0.27-0.93, P < 0.0001) and ACE inhibitors, angiotensin receptor blockers, statins and clopidogrel were not statistically significant. CONCLUSIONS: Hemodialysis patients with LVDys and ACS were commonly prescribed cardiac medications despite the poor level of direct evidence. Only beta-blockers were associated with improvements in mortality. Nephrologists practice patterns are based on extrapolations of the evidence from the non-ESRD population.