Factors determining angiotensin-converting enzyme inhibitor underutilization in heart failure in a community setting

Acute decompensated heart failure in a non cardiology tertiary referral centre, Sarawak General Hospital (SGH-HF)

Background

Data on clinical characteristics of acute decompensated heart failure (ADHF) in Malaysia especially in East Malaysia is lacking.

Methods

This is a prospective observational study in Sarawak General Hospital, Medical Department, from October 2017 to September 2018. Patients with primary admission diagnosis of ADHF were recruited and followed up for 90 days. Data on patient’s characteristics, precipitating factors, medications and short-term clinical outcomes were recorded.

Results

Majority of the patients were classified in lower socioeconomic group and the mean age was 59 years old. Hypertension, diabetes mellitus and dyslipidaemia were the common underlying comorbidities. Heart failure with ischemic aetiology was the commonest ADHF admission precipitating factor. 48.6% of patients were having preserved ejection fraction HF and the median NT-ProBNP level was 4230 pg/mL. Prescription rate of the evidence-based heart failure medication was low. The in-patient mortality and the average length of hospital stay were 7.5% and 5 days respectively. 43% of patients required either ICU care or advanced cardiopulmonary support. The 30-day, 90-day mortality and readmission rate were 13.1%, 11.2%, 16.8% and 14% respectively.

Conclusion

Comparing with the HF data from West and Asia Pacific, the short-term mortality and readmission rate were high among the ADHF patients in our study cohort. Maladaptation to evidence-based HF prescription and the higher prevalence of cardiovascular risk factors in younger patients were among the possible issues to be addressed to improve the HF outcome in regions with similar socioeconomic background.

Angiotensin-Converting Enzyme Inhibitors in Congestive Heart Failure: Practice versus Guidelines

Background:

Angiotensin-converting enzyme (ACE) inhibitors decrease morbidity and mortality in patients with systolic heart failure. In the practice of cardiology, ACE inhibitors are insufficiently prescribed by cardiologists.

Objective:

To measure the deviation between observed practice and clinical practice guidelines (CPGs), and to identify factors contributing to the deviation.

Methods:

CPGs have been developed from available international guidelines via a procedure involving a consensus group. A practice survey was conducted on 208 patients less than 75 years old hospitalized in public hospital cardiology units. Factors associated with nonadherence to CPGs were identified among characteristics of patients, practitioners, and cardiology units in logistic regression models.

Results:

In patients for whom the prescription of ACE inhibitors was not contraindicated, ACE inhibitor therapy was not initiated in 14%, and the CPR dosages were not attained in 51.2% of the cases. Factors associated with treatment not being initiated were age over 60 years (p = 0.001), increased ejection fraction (p = 0.005), and treatment with diuretics (p = 0.001) and digitalis glycosides (p = 0.008) at hospital admission. Factors associated with prescription of subtarget doses were age over 60 years (p = 0.024), low serum potassium concentration (p = 0.014), and absence of digitalis glycoside treatment (p = 0.039) at the start of ACE inhibitor administration.

Conclusions:

Our work has shown that cardiologists tend to adapt their prescription of ACE inhibitors to clinical situations that are not considered relevant in international guidelines. The implementation of CPGs in cardiology units should target adequate information about these situations.

Clinical and Therapeutic Profiles of Heart Failure Patients admitted to a Tertiary Hospital, Aseer Region, Saudi Arabia

OBJECTIVES

This study aimed to investigate the clinical and therapeutic profiles of heart failure (HF) cases admitted to Aseer Central Hospital (ACH), Saudi Arabia.

METHODS

A retrospective cohort of 300 consecutive patients admitted with the diagnosis of HF to ACH from 1 June 2007 to 31 May 2009 were included in the study. Data on demographic variables, aetiologic factors, risk factors, and therapeutic profiles of patients with HF were collected and analysed.

RESULTS

The patients' mean age was 67.4 ± 13.7 years and 68.7% of them were male. The commonest aetiologies for HF were ischaemic heart disease (IHD) and hypertension in 38.3% and 33.3% of patients, respectively. A total of 61.3% of patients were diabetics. Other risk factors for HF included renal failure in 9.7%, atrial fibrillation in 13%, and anaemia in 48.3% of patients. Echocardiography was performed in 98.7% of cases: the average ejection fraction (EF) was 33% ± 17. Angiotensin converting enzyme inhibitors (ACEI) or angiotensin 2 receptor blockers were used in 68.3% of cases, β-blockers in 51.6% of cases and digoxin in 28.3% of cases.

CONCLUSION

The major causes of HF in our study were IHD and hypertension. Diabetes and anaemia were common risk factors. The cohort constituted an intermediate HF risk group (ejection fraction (EF) 33%). Important therapeutic agents like angiotensin converting enzyme inhibitor I, β-blockers and digoxin were underutilised. Fostering such therapy in practice will lead to a better outcome in the management of HF patients. Anaemia was a significant risk factor in our HF patients and should be managed properly.

The Effect of Age upon Care and Outcomes in Patients Hospitalized for Congestive Heart Failure in Alberta, Canada

We describe the age-specific outcomes for patients hospitalized with newly diagnosed congestive heart failure using administrative hospital abstracts from Alberta, Canada, from April 1, 1994, to March 31, 2000. Seniors (aged 65 years and older) constituted about 85 per cent of the 16,162 patients. Both co-morbidity and severity of illness tended to increase with age. The use of special care unit admissions, coronary artery diagnostic services (cardiac catheterization), and revascularization procedures (percutanenous transluminal coronary angioplasty/stenting, coronary artery bypass surgery) peaked in the 50-to 64-year age group and decreased with increasing age. Specialist/sub-specialist care, prescriptions of beta blockers and angiotensin-converting enzyme inhibitors / angiotensin receptor blockers decreased with age in seniors. Adjusted in-hospital, 1-year mortality and crude, age-specific 5-year mortality were significantly greater in those 75 years and older. Outcomes and process of care in patients with newly diagnosed congestive heart failure were not uniformly distributed with age. The elderly had greater mortality but received less therapy.

CHART: congestive cardiac failure in hospitals, an Australian review of treatment

Despite strong evidence supporting the use of angiotensin-converting enzyme inhibitors (ACED, beta-blockers, and spironolactone in heart failure, evidence suggests these drugs are under-used and under-dosed. The aim of the present study was to determine the impact of hospitalisation on heart failure pharmacotherapy in patients with congestive heart failure (CHF). A retrospective study was conducted, based on 300 consecutive admissions with the medical record diagnosis of heart failure, in each of seven grade one teaching hospitals. At admission, 49.5% of patients were treated with ACEI, 19.2% with beta-blockers and 8.1% with spironolactone. Twenty-six per cent of untreated patients started ACEI treatment during their hospital stay, and 9.4% started beta-blockers The main determinants of treatment with ACEI at discharge were a primary diagnosis of heart failure (odds ratio (OR) = 1.886) and the presence of a potential contraindication (high creatinine OR = 0.458, cough OR = 0.187, renal artery stenosis OR = 0.309). Patients were less likely to be discharged on beta-blockers if greater than 85 years of age (OR = 0.545), or there was mention of airways disease (OR = 0.347), asthma (OR = 0.238) or type 2 diabetes (OR = 0.721) on the medical record. Patients admitted by a cardiologist were more likely to be discharged on beta-blockers (OR = 3.207). Spironolactone was more likely used in patients with primary diagnosis of heart failure (OR = 1.549), aged less than 85 years (OR = 0.319), and/or admitted by a cardiologist (OR = 1.827). The substantial number of patients admitted to hospital with a secondary diagnosis of heart failure should be targeted for therapeutic optimisation.

Therapies for acute heart failure in patients with reduced kidney function: a community-based perspective

BACKGROUND

Limited data exist describing the management of patients with decreased kidney function at the time of hospital presentation for acute heart failure (HF).

STUDY DESIGN

Nonconcurrent prospective study.

SETTING & PARTICIPANTS

Patients hospitalized with clinical findings of decompensated HF (n = 4,350) at all 11 greater Worcester, MA, medical centers in 1995 and 2000. Patients were categorized into varying levels of kidney function based on their estimated glomerular filtration rate (eGFR).

PREDICTOR

GFR estimates from serum creatinine levels measured at the time of hospital admission.

OUTCOMES

Hospital receipt of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), beta-blockers, digoxin, and diuretics.

MEASUREMENTS

Hospital charts were reviewed for prescribing of disease-modifying cardiac therapies, as well as therapies designed to provide symptomatic relief from HF.

RESULTS

Average eGFR in our study sample was 64.4 +/- 33.1 mL/min/1.73 m(2), and patients were categorized further into 3 eGFR levels of less than 30 (n = 569), 30 to 59 (n = 1,488), and 60 mL/min/1.73 m(2) or greater (n = 2,293) for comparative purposes. Patients with greater eGFRs (>or=60 mL/min/1.73 m(2)) were more likely to be treated with ACE inhibitors/ARBs (56% versus 39%) and digoxin (51% versus 46%) during hospitalization for HF than patients with lower eGFRs (<30 mL/min/1.73 m(2); P < 0.05). Patients with lower eGFRs (<30 mL/min/1.73 m(2)) were more likely to be prescribed beta-blockers than patients with greater eGFRs (>or=60 mL/min/1.73 m(2); 46% versus 39%; P < 0.01). Use of ACE inhibitors/ARBs increased between 1995 and 2000 in 2 of the 3 eGFR groups examined: eGFRs less than 30 mL/min/1.73 m(2) (33% in 1995; 42% in 2000) and eGFRs of 60 mL/min/1.73 m(2) or greater (51% in 1995; 59% in 2000). Use of beta-blockers increased appreciably in all 3 eGFR groups (<30 mL/min/1.73 m(2), 27% in 1995; 58% in 2000; >or=60 mL/min/1.73 m(2): 25% in 1995; 49% in 2000). However, less than one third of all patients were treated with both disease-modifying therapies in 2000.

LIMITATIONS

We were unable to classify patients into those with systolic versus diastolic HF.

CONCLUSIONS

Our results suggest that use of disease-modifying therapies for patients hospitalized with clinical findings of acute HF and decreased kidney function remains less than desirable. Educational programs are needed to enhance the management of patients with decreased kidney function who develop HF.

Do ACE Inhibitors/Angiotensin II type 1 receptor antagonists reduce hospitalisations in older patients with heart failure? A propensity analysis

BACKGROUND

Randomised controlled trials have shown a reduced risk of heart failure (HF) hospitalisation among users of ACE inhibitors (ACEIs) or angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]), but these results have limited generalisability. Some observational studies have also demonstrated reductions in hospitalisation but are potentially affected by non-random treatment selection.

OBJECTIVE

To assess the effect of ACEI/ARB therapy on all-cause and HF-related hospitalisations among older adults using a propensity model to adjust for treatment-selection bias and focusing on consistent medication use as the exposure of interest.

METHODS

A retrospective cohort study of continuously enrolled, older (age > or =60 years) Kansas Medicaid beneficiaries with HF, using data from May 1999 to April 2000. A propensity analysis was used to identify a comparison group of untreated persons that were otherwise clinically similar to treated persons. The effect of regular ACEI/ARB use on hospitalisations was estimated using multivariable logistic regression models. The HF sample included 887 subjects, of whom 235 (27%) received regular ACEI/ARB therapy. To be considered a regular user of ACEI/ARB therapy ('treated'), we required evidence that a subject obtained at least 80% of their intended daily supply. The main outcome measure was the effect of regular ACEI/ARB use on all-cause and HF-related hospitalisations.

RESULTS

Treated subjects were matched against an equal number of untreated persons, for a final sample of 470 persons. The mean age of both treated and untreated subjects was 81 years. Regular ACEI/ARB use did not alter the adjusted odds ratio (AOR) of all-cause hospitalisation (AOR = 1.04, 95% CI 0.71, 1.52), which occurred in 40% of the sample, or the odds of an HF-related hospitalisation (AOR = 1.01, 95% CI 0.65, 1.57), which occurred in 22.6% of both groups.

CONCLUSION

Although randomised controlled trials have shown that ACEI/ARB treatment is associated with reduced hospitalisations in patients with HF, this benefit was not observed in our study. Further study of ACEI/ARB outcomes is needed in a larger sample of older subjects with HF.

Analysis of ambulatory heart failure management and its incidence on one-year survival

AIM

To assess in a daily practice survey one-year survival in a cohort of patients with heart failure (HF) according to their clinical profiles and the way they were managed by cardiologists.

METHODS AND RESULTS

A prospective observational survey was conducted in 1941 patients with HF followed up for one year. Results show high rates of prescription for ACE inhibitors, indicating that cardiologists take into account international recommendations. ACE inhibitors are prescribed at dosage levels approaching those recommended by the guidelines. However, beta-blocker prescription still shows a significant deficit and the prescribed doses are much lower than those currently recommended. The multifactorial modeling analysis showed that global heart failure (P=0.004), advanced NYHA class (P<0.001), renal failure (P<0.001) were predictive of poor outcome whereas an increased survival likelihood was observed in patients given ACE-inhibitor/beta-blocker combination compared with beta-blocker alone or ACE-inhibitor alone.

CONCLUSION

The results from this study should enhance the prescription of ACE inhibitors and beta-blockers at effective doses in compliance with the guidelines. They also suggest that a synergic positive effect of the combination of these two therapeutic classes is observed in real life situations.

Effects of applying a standardised management algorithm for moderate to severe renal dysfunction in patients with chronic stable heart failure

BACKGROUND

No specific guidelines exist on how to manage renal dysfunction (RD) in patients with chronic heart failure (CHF).

AIMS

To identify the proportion of patients with moderate to severe RD and CHF who showed an improvement in their renal function in response to a systematic management algorithm.

METHODS

Stable patients with CHF and RD (defined by a serum creatinine (SCr) of >130 micromol/l (>1.5 mg/dl)) were enrolled into a systematic management algorithm. The following changes were implemented: switching aspirin to clopidogrel, halving the dose of both diuretics and angiotensin converting enzyme (ACE) inhibitors and switching between bisoprolol and carvedilol.

RESULTS

Two thirds of patients in whom diuretics were reduced, and one fifth of patients in whom ACE inhibitors were reduced, improved their SCr by >25.5 micromol/l (0.3 mg/dl). All these changes were more marked in the presence of bilateral renal artery stenosis. Compared to a reference group, in whom no changes were implemented, the treatment group showed an improvement in their mean SCr by 35 micromol/l (0.4 mg/dl), p<0.001.

CONCLUSION

Manipulation of pharmacological therapy for patients with CHF and RD results in a substantial recovery of renal function in a minority of patients.

Aldosterone antagonists: the most underutilized class of heart failure medications

BACKGROUND

Aldosterone antagonists have been proven to be beneficial in severe heart failure (HF) as a result of systolic dysfunction. We sought to determine if there is a disparity in their utilization compared with ACE inhibitors and beta-adrenoceptor antagonists (beta-blockers).

METHODS

In the first part of the study, we asked physicians to answer a questionnaire presenting a hypothetical HF patient. In the second part, we reviewed hospital charts of patients with HF exacerbation.

RESULTS

Spironolactone was used less frequently than other drugs. At home, 75.0% of patients were receiving ACE inhibitors, 66.7% received beta-blockers, and 38.2% received spironolactone (p < 0.001). During the admission, 93.1% of patients received ACE inhibitors and 58.3% received spironolactone (p < 0.001).

CONCLUSIONS

Despite good evidence, underutilization of aldosterone antagonists in patients matching the population of the RALES (Randomized Aldactone Evaluation Study) trial persists in both outpatient and inpatient settings. The difference between the usage of ACE inhibitors and spironolactone is significant in patients with systolic dysfunction equally qualifying for both medications.

Use of disease-modifying therapies in patients hospitalized with heart failure: a population-based perspective

BACKGROUND

Little data are available about the hospital management of patients with decompensated heart failure (HF) with individual and combination medical therapies, particularly from the more generalizable perspective of a population-based investigation. The purpose of our study was to describe the use of different cardiac medications in 2463 patients with new-onset HF who were discharged from all greater Worcester, Massachusetts, hospitals during 2000.

METHODS

On the basis of a review of medical records, we examined the prescribing of 2 classes of cardiac medications that have been shown to improve the long-term prognosis of patients with HF (angiotensin pathway inhibitors and beta-blockers). We also examined the use of 2 therapies commonly used to improve the symptomatic status of patients with acute HF (diuretics and digoxin).

RESULTS

The mean age of the study sample was 76 years, and 57% were women. Approximately 1 in 5 patients were not prescribed beta-blockers or angiotensin inhibitors during their index hospitalization, whereas 1 in 3 patients were discharged with both of these effective cardiac medications. Diuretics were prescribed for virtually all patients (98%), followed by the use of digoxin in approximately half of patients (48%). The receipt of both beta-blockers and angiotensin pathway inhibitors was associated with several demographic, medical history, and clinical factors. Patients treated with both effective cardiac medications were also more likely to be counseled to monitor or modify several lifestyle factors that have been shown to be effective adjuncts to the medical management of patients with HF.

CONCLUSIONS

Considerable opportunity remains for the more optimal hospital management of patients with decompensated HF.

Enhancing quality of heart failure care in managed Medicare and Medicaid in North Carolina: results of the North Carolina Achieving Cardiac Excellence (NC ACE) Project

OBJECTIVES

To evaluate an intervention to improve the quality of care of patients with heart failure in managed Medicare and Medicaid plans in North Carolina.

BACKGROUND

Utilization of angiotensin-converting enzyme inhibitors (ACE-I) and beta-adrenergic receptor blockers (BB) in heart failure (HF) patients remains suboptimal despite evidence-based guidelines supporting their use.

METHODS

Managed care plans identified adult patients with HF during 2000 (preintervention) and from July 1, 2001, through June 30, 2002 (postintervention). Outpatient medical records were reviewed to obtain data regarding type of heart failure, demographics, comorbidities, and therapies. The intervention consisted of guideline summary dissemination, performance audit with feedback, patient-specific chart reminders, and patient activation mailings.

RESULTS

We sampled 1613 patients from 5 plans during the preintervention period and 1528 patients during the postintervention period. Assessment of left ventricular function (LVF) increased from 88.2% to 92.5% of patients (P < .0001). Among patients with moderate to severe left ventricular systolic dysfunction, there was no substantive change in treatment with ACE-I or vasodilators, whereas, appropriate treatment with BB increased from 48.3% (with another 11.9% with documented contraindications) to 67.9% (with another 7.5% with documented contraindications). The quality gap decreased from 39.8% to 24.6% (P < .0001).

CONCLUSION

LVF assessment improved despite high preintervention rates. Treatment rates with ACE-I and vasodilators remained high, but did not improve. Treatment rates with BB improved substantially translating into a significant public health benefit. Health-care payers should consider development of financial incentives to encourage collaborative quality improvement programs.

Heart Failure Drug Utilization Patterns for Medicaid Patients Before and After a Heart Failure-Related Hospitalization

The authors examined heart failure (HF) drug utilization patterns in Medicaid patients before and after a HF-related hospitalization. This was a retrospective claims analysis of Kansas Medicaid beneficiaries hospitalized for HF between July 1, 2000, and March 31, 2001. HF drugs were tracked 6 months prior and 6 months following the admission. Angiotensin-converting enzyme (ACE) inhibitor doses were compared with target ranges. The cohort of 135 patients had a mean age of 53.6 years and was predominantly female (66.7%) and Caucasian (70.4%) with a high prevalence of cardiovascular comorbidities. Before hospitalization, less than one third of patients were receiving ACE inhibitors, angiotensin receptor blockers, beta blockers, digoxin, or vasodilators. Following hospitalization, increased utilization was observed for beta blockers, digoxin, and angiotensin receptor blockers, but overall usage remained low. ACE inhibitors and vasodilator use remained constant. ACE-inhibitor doses were below target ranges before and after hospitalization. In this Medicaid cohort, HF-related hospitalizations did not lead to improved HF therapy.

Aetiology, comorbidity and drug therapy of chronic heart failure in the real world: the EPICA substudy

BACKGROUND

Chronic heart failure (CHF) is common and is frequently managed by primary care physicians (PCPs). Despite the European Society of Cardiology (ESC) Guidelines, standard treatments for CHF are frequently underutilised, particularly in primary care.

AIM

To evaluate current drug therapy for CHF in adults with HF diagnosed according to ESC guidelines in the context of the EPICA study. Aetiological features and therapy relevant comorbidities were also analysed.

METHODS

EPICA was a community-based epidemiological study conducted in mainland Portugal. The study involved 365 primary care physicians, who evaluated 6300 primary care attendees aged over 25 years. CHF was diagnosed by clinical and echocardiography criteria according to ESC guidelines.

RESULTS

Total of 551 cases of CHF were identified, with a mean age of 65+/-9 years. The estimated overall prevalence of CHF in the Portuguese population was 4.4%; 1.3% with and 1.7% without left ventricular systolic dysfunction (LVSD). There are 6,280,792 people aged >25 years in Portugal, which extrapolates to 261,400 cases of heart failure. About 80% of patients had a history of hypertension, 39% had a history of coronary artery disease and 15% had atrial fibrillation. Only 58% of patients were on angiotensin-converting enzyme (ACE) inhibitors and 7% on beta-blockers. The type of ventricular dysfunction, age and presence of renal failure had little effect on prescription rates. Diuretics were prescribed in 78%. Thiazides were used more frequently in those with preserved systolic function and frusemide in those with left ventricular systolic dysfunction. Digoxin was prescribed more often to patients with than without left ventricular systolic dysfunction (34% vs. 17%; p=0.02). Long-acting nitrates were prescribed to 20% and amiodarone to 8% of patients.

CONCLUSION

The EPICA study, as in other studies in primary care in Europe, particularly the IMPROVEMENT study, suggests that greater efforts are required to improve training of primary care teams in the management of CHF.

Beta-blocker therapy for heart failure outside the clinical trial setting: findings of a community-based registry

BACKGROUND

beta-Blockers reduce morbidity and mortality rates in heart failure (HF) clinical trials, but it is unknown whether these findings persist in the community setting.

METHODS

A registry was created to survey tolerability and outcomes during initiation and 1-year follow-up of beta-blocker treatment with carvedilol in patients with HF treated by cardiologists (CARD) and primary care physicians (PCP) in the community.

RESULTS

A total 4280 patients were enrolled (3121 by 259 CARD, 1159 by 129 PCP). Patient age averaged 67 +/- 13 years; 35% were women and 12% were black. The left ventricular ejection fraction averaged 31 +/- 12; New York Heart Association class was II-III in 86% and IV in 3%. Patients of PCP had higher left ventricular ejection fraction, were older, and more frequently were female, black, diabetic, hypertensive, and in New York Heart Association class III/IV. Minimal difficulty titrating carvedilol was noted by >80% of CARD and PCP. Significantly more CARD-treated patients reached carvedilol doses of 25 mg twice daily (49% vs 27%). Kaplan-Meier all-cause mortality rate was 8.5% at 1 year and did not differ between CARD-treated and PCP-treated patients (8.2% vs 9.3%, P =.254). At least one HF hospitalization occurred in 11% of patients during follow-up, compared with 28% in the preceding year.

CONCLUSIONS

Community-based physicians use carvedilol with success approaching that of clinical trials. Overall mortality rates and HF hospitalizations were in the same low range as in clinical trials. Thus, it appears that results of clinical trials with carvedilol for HF can be translated to the community setting.

Use of Angiotensin-Converting Enzyme Inhibitors in Elderly People With Heart Failure: Prevalence and Outcomes

BACKGROUND

There is a lack of information on the effects of angiotensin-converting enzyme (ACE) inhibitors in very old people with heart failure (HF). The objective of this study is to estimate the prevalence of prescriptions of ACE inhibitors in elderly people with HF discharged from acute care hospitals, and to evaluate the effect of these drugs on 1-year mortality rates.

METHODS

We used data from the Gruppo Italiano di Farmacovigilanza nell'Anziano (GIFA). In 1998, we undertook a 1-year longitudinal study on elderly people (aged 65+ years) discharged with a diagnosis of HF. We compared the demographic and clinical characteristics associated with a prescription at discharge of ACE inhibitors, and used a Cox proportional hazard regression model to calculate the relative hazard of dying associated with the use of ACE inhibitors.

RESULTS

We enrolled 818 patients in the study with a mean age of 79 years (range: 65-101 years). One fourth of the participants were aged 85 years or older. ACE inhibitors were prescribed to 550 patients (67.2%) at discharge. Older age and physical disability were negatively correlated with the use of ACE inhibitors. People using ACE inhibitors had a 40% reduction of mortality (HR [hazard ratio]: 0.60; 95% CI [confidence intervals]: 0.42-0.88). The reduction in mortality was much stronger among disabled people (HR: 0.35; 95% CI: 0.19-0.64).

CONCLUSION

ACE inhibitors are still underprescribed among elderly people with HF discharged from acute care hospitals. Even in this frail, elderly population, we found a beneficial effect of ACE inhibitors. There is room to further improve the quality of care for elderly people with HF.

A survey of outpatient management of elderly heart failure patients in Poland—treatment patterns

BACKGROUND

Despite the fact that heart failure constitutes a major health problem there are only limited data regarding pharmacotherapy along with characterization and prognosis of heart failure in the community.

AIM

The aim of this study was to investigate treatment pattern in ambulatory patients with heart failure.

METHODS

The study is a cross-country epidemiological survey, based on registration, by 417 participating physicians, 50 consecutive ambulatory patients aged >/=65 years seeking medical care for any cause.

RESULTS

From a total of 19,877 individuals, 10,579 patients (3901 men and 6678 women, 53% of total) were diagnosed with HF. Therapy with angiotensin converting enzyme inhibitors was recommended in 68%, long acting nitrates in 62%, diuretics in 55%, cardiac glycosides in 31%, Ca blockers in 29% and beta blockers in 22% of all individuals with HF. The prevalence of particular groups of drugs administered in both genders was similar with the exception for calcium blockers, which were more frequently used in women (p<0.001), whereas long acting nitrates in men (p<0.001). In general, angiotensin converting enzyme inhibitors, long acting nitrates and cardiac glycosides use increased with age. On the contrary, beta blockers and calcium blockers were given mostly to younger patients. The most sick patients were more likely to receive angiotensin converting enzyme inhibitors, cardiac glycosides, long acting nitrates and diuretics, whereas less frequently beta blockers and calcium blockers. Combination therapy was used relatively rarely, with lowest percentage in NYHA IV.

CONCLUSION

Compared to the other population studies, both angiotensin converting enzyme inhibitors and beta blockers were used relatively more frequently, although in the absolute terms the latter was clearly underused. The high rate of Ca blockers prescription is a matter of concern. More attention should be paid to optimising combination usage and introducing beta blockers early in all stable patients.

Quality of heart failure care in managed Medicare and Medicaid patients in North Carolina

Use of angiotensin-converting enzyme (ACE) inhibitors and beta-adrenergic receptor blockers in patients with heart failure (HF) remains low despite the results of clinical trials and evidence-based guidelines that support their use. The quality of HF care in managed Medicare and Medicaid programs in North Carolina participating in a HF quality improvement program was assessed. Managed care plans identified adult patients with 1 inpatient or 3 outpatient claims for HF during 2000. A stratified random sample of 971 Medicare and 642 Medicaid patients' outpatient medical records from 5 plans were reviewed by trained nurse abstractors to obtain data regarding type of HF, demographics, comorbidities, and therapies. Left ventricular function assessment was performed in 88% of patients. Among 494 patients with systolic dysfunction, 86% were appropriately treated with respect to ACE inhibitors (73% prescribed, 13% had a documented contraindication). In contrast, beta-blocker therapy was appropriate in 61% (49% prescribed, 12% contraindication). There were no significant differences in drug use by insurance, gender, race, or age. Ventricular function assessment and ACE inhibitor prescription rates are higher than beta-blocker prescription rates among Medicare and Medicaid managed care patients in North Carolina. Opportunities for improvement remain, particularly for beta-blocker use.

Outcomes and Costs Among Seniors Requiring Hospitalization for Community-Acquired Pneumonia in Alberta

OBJECTIVES

To determine the age-specific rates of hospital discharge, cost per day, and overall in-hospital 1- and 4-year mortality for seniors who required hospitalization for the treatment of community-acquired pneumonia (CAP).

DESIGN

Retrospective analysis of two administrative health service databases.

SETTING

Province of Alberta, Canada.

PARTICIPANTS

Residents of Alberta aged 18 and older.

MEASUREMENTS

Hospital abstracts and vital statistics from April 1, 1994, to March 31, 1999, were analyzed, and mortality and cost outcomes statistically modeled by regression.

RESULTS

There were 8,500 annual hospital discharges for CAP costing more than $40 million per year. The overall in-hospital all-cause mortality rate was 12%, and the 1-year mortality rate was 26%. The mean age of pneumonia cases increased (P<.000) from 62.8 in 1994/1995 to 67.2 in 1998/1999. The proportion of hospital discharges in those aged 85 and older was 13% in 1994/1995, increasing to 18% in 1998/1999 (P<.000). The age-specific hospital discharge rate and length of hospitalization increased with age. After adjustment for other factors using modeling, it was found that the relative risk (RR) of in-hospital and 1-year mortality increased with age, the RR of using special medical care and higher-than-average daily hospital cost decreased with age, and the RR of greater-than-average daily hospital cost was not associated with an increase in comorbidity. Total costs per hospital stay were similar in patients aged 85 and older to those in patients aged 65 to 74, despite a one-third longer length of stay, which was consistent with reduced use of special medical care in those aged 85 and older.

CONCLUSION

The increased use of hospital resources for CAP in the setting of an aging population may have been partially avoided because of limitations in care provided for seniors aged 85 and older.

Improving ACE inhibitor use in patients hospitalized with systolic heart failure: a cluster randomized controlled trial of clinical practice guideline development and use

RATIONALE, AIMS AND OBJECTIVES

The efficacy of angiotensin-converting enzyme (ACE) inhibitors in treating heart failure is well established, but there is concern that these agents are underutilized. This study aimed to evaluate the effect of developing and implementing Clinical Practice Guidelines (CPGs) on the quality of care given to patients receiving ACE inhibitors for systolic heart failure.

METHODS

Twenty cardiology units in Lorraine (France) were randomized to an experimental (n = 10) or a control group (n = 10). In each experimental unit, doctors were involved in drafting and implementing CPGs; those at control units were not. Practice surveys were conducted in all units before and after the intervention; 723 patients with heart failure and less than 75 years old were included. The main outcome was compliance with the CPGs.

RESULTS

Before intervention, clinicians in both groups were already compliant with CPGs relating to indications and contra-indications, adverse effects management, concomitant therapy and monitoring of biologic factors. After intervention, adherence to others CPGs was generally better in the experimental group. Compliance with the CPG relating to ACE inhibitor dose on discharge was higher in the experimental group (P = 0.003). Compliance with CPGs relating to increasing ACE inhibitors doses (P < 0.0001) and the contents of the discharge letter (P = 0.02) improved in all units between the two periods.

CONCLUSIONS

These results suggest that doctors involved in drafting and implementing CPGs are more likely to comply with them.

Heart failure in a multiethnic population in Kuala Lumpur, Malaysia

BACKGROUND

There are established differences in cardiovascular disease in different racial groups. Worldwide, the literature regarding the clinical epidemiology of congestive heart failure (CHF) in non-white populations is scarce.

OBJECTIVES

To document the prevalence of CHF in the multiracial population of Malaysia, and to describe the clinical features and management of these patients.

SETTING

Busy city centre general hospital in Kuala Lumpur, Malaysia.

RESULTS

Of 1435 acute medical admissions to Kuala Lumpur General Hospital over the 4-week study period, 97 patients (6.7%) were admitted with the primary diagnosis of CHF. Coronary artery disease was the main aetiology of CHF, accounting for almost half (49.5%) the patients, followed by hypertension (18.6%). However, there were variations in associated aetiological factors between ethnic groups, with diabetes mellitus affecting the majority of Indians-as well as underutilisation of standard drugs for CHF, such as the angiotensin converting enzyme (ACE) inhibitors, which were only used in 43.3%.

CONCLUSION

Amongst acute medical admissions to a single centre in Malaysia the prevalence of CHF was 6.7%. Coronary artery disease was the major aetiological factor in heart failure accounting for almost half the admissions. The under-prescription of ACE inhibitors was similar to other clinical surveys carried out amongst Caucasian populations in the West.

[Angiotensin-converting enzyme inhibitors in congestive heart failure: clinical practice guidelines]

Angiotensin-converting enzyme (ACE) inhibitors are, at present, the cornerstone of therapy for congestive heart failure. Nevertheless, international literature and regional data have reported their underutilisation in the practice of cardiology. Despite the abundance of consensus conferences, none deal specifically with a therapeutic strategy using ACE inhibitors. In this context, clinical practice guidelines on the management of systolic heart failure with ACE inhibitors have been drafted in Lorraine by hospital cardiologists. The guidelines were formulated using a standardised procedure, combining a literature analysis and the opinions of experts. Seventeen guidelines were finally adopted, under four headings: indications and contraindications for ACE inhibitors; dosages and approaches to treatment monitoring; the management of adverse effects; and contraindications for concomitant therapy. The drafting of the clinical practice guidelines is the first step in a quality improvement programme, initiated in 1999 in the cardiology wards of the region.

Improving guideline adherence: a randomized trial evaluating strategies to increase beta-blocker use in heart failure

BACKGROUND

The dissemination of clinical practice guidelines often has not been accompanied by desired improvements in guideline adherence. This study evaluated interventions for implementing a new practice guideline advocating the use of beta-blockers for heart failure patients.

METHODS AND RESULTS

This was a randomized controlled trial involving heart failure patients (n=169) with an ejection fraction < or =45% and no contraindications to beta-blockers. Patients' primary providers were randomized in a stratified design to 1 of 3 interventions: (1) control: provider education; (2) provider and patient notification: computerized provider reminders and patient letters advocating beta-blockers; and (3) nurse facilitator: supervised nurse to initiate and titrate beta-blockers. The primary outcome, the proportion of patients who were initiated or uptitrated and maintained on beta-blockers, analyzed by intention to treat, was achieved in 67% (36 of 54) of patients in the nurse facilitator group compared with 16% (10 of 64) in the provider/patient notification and 27% (14 of 51) in the control groups (P<0.001 for the comparisons between the nurse facilitator group and both other groups). The proportion of patients on target beta-blocker doses at the study end (median follow-up, 12 months) was also highest in the nurse facilitator group (43%) compared with the control (10%) and provider/patient notification groups (2%) (P<0.001). There were no differences in adverse events among groups.

CONCLUSIONS

The use of a nurse facilitator was a successful approach for implementing a beta-blocker guideline in heart failure patients. The use of provider education, clinical reminders, and patient education was of limited value in this setting.

Patterns of pharmacotherapy in patients hospitalised for congestive heart failure

BACKGROUND

In the 1990s, a number of cardiovascular drugs were evaluated in randomised clinical trials. Treatment guidelines for heart failure were modified to include these evidence-based treatments.

AIM

To evaluate the impact of new medical treatments for heart failure between 1990 and 1998.

METHODS AND RESULTS

A retrospective cohort study of 2764 patients with a first hospital admission for heart failure between 1990 and 1998. The percentage of patients treated with different cardiovascular drugs after hospitalisation was calculated and compared over time. Use of loop diuretics remained steady approximately 80%, digoxin decreased from 57.6 to 42.7%, angiotensin converting enzyme (ACE) inhibitors showed a slight increase from 49.8 to 54.8%, beta-blockers almost tripled from 11.3 to 28.7%, low dose prophylactic acetylsalicylic acid quadrupled from 9.9 to 39.9%. Kaplan-Meier survival estimates showed highest continuation rates of drug treatment for antithrombotics and diuretics, intermediate for digoxin and ACE inhibitors and low for beta-blockers. More than a quarter of the users discontinued beta-blockers in the first year after hospitalisation.

CONCLUSIONS

We observed an increase in the prescribing of several important drug classes, reflecting changes in treatment guidelines during the study period. However, our findings show that not all patients were receiving optimal treatment. More research into the reasons for this is warranted.

Heart failure in the elderly: strategies to optimize outpatient control and reduce hospitalizations

Heart failure is a disorder that disproportionately affects the elderly, and over 50% of heart failure hospitalizations in the United States occur in persons over 75 years of age. Moreover, despite recent advances in heart failure therapy, optimal treatment of elderly patients remains undefined. In addition, heart failure management in older persons is often complicated by the presence of multiple comorbid conditions, polypharmacy, psychosocial and behavioral concerns, dietary issues, and economic considerations. As a result, management of heart failure in the elderly requires a coordinated, multidisciplinary approach, and a series of recent studies have documented the efficacy of heart failure disease management programs in reducing readmissions, enhancing medication and dietary compliance, and lowering cost of care. Ongoing studies will provide insights into the feasibility and effectiveness of implementing heart failure disease management programs on a population-wide basis, and on the effects of such programs on long-term clinical outcomes and costs.

Can treatment with angiotensin-converting enzyme inhibitors in elderly patients with moderate to severe chronic heart failure be improved by a nurse-monitored structured care program? A randomized controlled trial

OBJECTIVE

The purpose of this study was to examine whether a nurse-monitored structured care program resulted in a more effective use of angiotensin-converting enzyme (ACE) inhibitors in elderly patients compared with standard care in patients with chronic heart failure (CHF).

METHODS

Hospitalized patients were screened to identify individuals with CHF, age more than 65 years, New York Heart Association classification III to IV, and no contraindications to ACE inhibitor treatment. One hundred forty-five patients were randomized to a nurse-monitored structured care program that included uptitration of enalapril to a target dose of 10 mg twice a day or to standard care. Six-month follow-up data were collected.

RESULTS

The mean age of the randomized patients was 81 years. Although the proportion of patients treated with an ACE inhibitor did not differ between structured care (70%) and standard care (64%), the number of patients with the target ACE inhibitor dose was significantly higher in the structured care group (26% versus 11% in the standard care group; P <.018). Treatment had to be discontinued in 26% of the patients because of adverse effects.

CONCLUSION

The patients in this study were older than in previous intervention studies and had considerable comorbidity and reduced tolerance for ACE inhibitors. ACE inhibitor treatment was underused but improved with the structured care program, although achieved treatment levels were below those in the large intervention trials in patients with CHF.

Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey

BACKGROUND

Heart failure is a prevalent condition that is generally treated in primary care. The aim of this study was to assess how primary-care physicians think that heart failure should be managed, how they implement their knowledge, and whether differences exist in practice between countries.

METHODS

The survey was undertaken in 15 countries that had membership of the European Society of Cardiology (ESC) between Sept 1, 1999, and May 31, 2000. Primary-care physicians' knowledge and perceptions about the management of heart failure were assessed with a perception survey and how a representative sample of patients was managed with an actual practice survey.

FINDINGS

1363 physicians provided data for 11062 patients, of whom 54% were older than 70 years and 45% were women. 82% of patients had had an echocardiogram but only 51% of these showed left ventricular systolic dysfunction. Ischaemic heart disease, hypertension, diabetes mellitus, atrial fibrillation, and major valve disease were all common. Physicians gave roughly equal priority to improvement of symptoms and prognosis. Most were aware of the benefits of ACE inhibitors and beta blockers. 60% of patients were prescribed ACE inhibitors, 34% beta blockers but only 20% received these drugs in combination. Doses given were about 50% of targets suggested in the ESC guidelines. If systolic dysfunction was documented, ACE inhibitors were more likely and beta blockers less likely to be prescribed than when there was no evidence of systolic dysfunction.

INTERPRETATION

Results from this survey suggest that most patients with heart failure are appropriately investigated, although this finding might be as a result of high rates of hospital admissions. However, treatment seems to be less than optimum, and there are substantial variations in practice between countries. The inconsistencies between physicians' knowledge and the treatment that they deliver suggests that improved organisation of care for heart failure is required.

Long-term trends in the incidence of and survival with heart failure

BACKGROUND

Heart failure is a major public health problem. Long-term trends in the incidence of heart failure and survival after its onset in the community have not been characterized.

METHODS

We used statistical models to assess temporal trends in the incidence of heart failure and Cox proportional-hazards regression to evaluate survival after the onset of heart failure among subjects in the Framingham Heart Study. Cases of heart failure were classified according to the date of onset: 1950 through 1969 (223 cases), 1970 through 1979 (222), 1980 through 1989 (307), and 1990 through 1999 (323). We also calculated 30-day, 1-year, and 5-year age-adjusted mortality rates for each period.

RESULTS

Heart failure occurred in 1075 subjects (51 percent of whom were women). As compared with the rate for the period from 1950 through 1969, the incidence of heart failure remained virtually unchanged among men in the three subsequent periods but declined by 31 to 40 percent among women (rate ratio for the period from 1990 through 1999, 0.69; 95 percent confidence interval, 0.51 to 0.93). The 30-day, 1-year, and 5-year age-adjusted mortality rates among men declined from 12 percent, 30 percent, and 70 percent, respectively, in the period from 1950 through 1969 to 11 percent, 28 percent, and 59 percent, respectively, in the period from 1990 through 1999. The corresponding rates among women were 18 percent, 28 percent, and 57 percent for the period from 1950 through 1969 and 10 percent, 24 percent, and 45 percent for the period from 1990 through 1999. Overall, there was an improvement in the survival rate after the onset of heart failure of 12 percent per decade (P=0.01 for men and P=0.02 for women).

CONCLUSIONS

Over the past 50 years, the incidence of heart failure has declined among women but not among men, whereas survival after the onset of heart failure has improved in both sexes. Factors contributing to these trends need further clarification.

Patterns of ACE inhibitor use in elderly medicaid patients with heart failure

The authors identified 321 elderly Kansas Medicaid patients with congestive heart failure and examined angiotensin-converting enzyme (ACE) inhibitor use. Using retrospective claims data, ACE inhibitor use was quantified and daily doses compared to a target enalapril-equivalent dose of 20 mg. The cohort patients averaged 80 years of age, 84% were female, and 70% resided primarily in a nursing home. Only 37.8% received an ACE inhibitor. Users were younger than nonusers (t=2.00; p=0.046), but there was no gender difference (odds ratio [OR], 1.4; 95% confidence interval [CI], 0.73, 2.6). ACE inhibitor users averaged eight prescriptions annually, providing approximately 257 medication days (70% of the study period). The average enalapril-equivalent daily dose was 10.6 mg, and only 22% received the target dose. Nursing home residents were less likely to receive an ACE inhibitor than ambulatory patients (OR, 0.55; 95% CI, 0.34, 0.89) but equally likely to receive target doses (OR, 1.3; 95% CI, 0.34, 4.9). ACE inhibitor use in the Kansas Medicaid congestive heart failure population is not consistent with practice guidelines, particularly among older and/or nursing home patients.

Cardiac troponin I: a potential marker of exercise intolerance in patients with moderate heart failure

BACKGROUND

In severe heart failure, increased values of cardiac troponins have been detected during decompensation. In this study, we investigated whether an increase of cardiac troponin I can be observed after symptom-limited exercise and after an exercise training session in patients with moderate heart failure.

METHODS

Twenty-seven patients with moderate heart failure (New York Heart Association II-III, ejection fraction 31% +/- 8%) were compared with 9 patients with mild heart failure and 10 subjects without heart failure. They underwent a symptom-limited exercise test and a bicycle exercise training session at >80% of maximal heart rate over 20 to 30 minutes. Plasma cTnI levels were measured at baseline, after symptom-limited exercise (hourly for 5 hours), and after training (4 and 10 hours).

RESULTS

Patients with moderate heart failure showed an increase of cTnI from 37 +/- 49 pg/mL to 73 +/- 59 pg/mL (P <.001) after symptom-limited exercise. Four patients with moderate and 1 with mild heart failure and normal cTnI values at rest showed an increase of cTnI above 100 pg/mL after acute exercise but not after training. Subjects without heart failure had lower cTnI levels at rest and significantly lower values after symptom-limited exercise and training (P <.05 for each).

CONCLUSION

Patients with symptomatic heart failure reveal an increase of cTnI after symptom-limited exercise at levels that indicate minor myocardial damage. The prognostic impact of this finding should, therefore, be further investigated.

Use of angiotensin-converting enzyme inhibitors in patients with heart failure and renal insufficiency: how concerned should we be by the rise in serum creatinine?

PURPOSE

To determine the association between the early rise in serum creatinine levels associated with the use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and the long-term renoprotective properties of these drugs in patients with chronic renal insufficiency.

BACKGROUND

Large-scale clinical trials have demonstrated survival benefits of ACE inhibitors in patients with heart failure. In patients with renal insufficiency, whether associated with diabetes mellitus or not, use of ACE inhibitors is associated with slowing in the progression of renal disease. In fact, patients who have the most advanced renal insufficiency at baseline are the ones who show the maximum slowing of the disease progression, but these patients are also more likely to show an early rise in serum creatinine levels after ACE inhibitor therapy. There is evidence that patients with renal insufficiency often do not receive ACE inhibitors. There is also evidence that patients with heart failure are not receiving this life-saving drug or are receiving it at dosages lower than that used in the clinical trials. One of the main reasons for this underutilization of ACE inhibitors in patients with heart failure is the underlying renal insufficiency or the rise in serum creatinine level after initiation of therapy with an ACE inhibitor.

METHODS

The authors reviewed 12 randomized clinical trials of ACE inhibitor or ARB therapy in patients with preexisting chronic renal insufficiency, with or without diabetes mellitus or heart failure. Studies were included for review if they met the following criteria: subjects were randomized to receive ACE inhibitor; subjects were followed up for a minimum of 2 years; and most of the subjects had baseline chronic renal insufficiency (>or=25% loss of renal function), irrespective of cause. Of the 12 studies that met these criteria, six were multicenter double-blind placebo-controlled studies. The other six were smaller randomized studies. The studies had a mean +/- standard deviation follow-up of 3.2 +/- 0.3 years. One thousand one hundred two patients were randomized to receive ACE inhibitors or ARBs. Of these, 705 (64%) had data on renal function at baseline (within 6 months of the start) and at the end of the study. The authors examined the changes in serum creatinine levels or glomerular filtration rates (GFR) in patients who were randomized to receive ACE inhibitors. The authors also assessed the blood pressures achieved in the trials.

RESULTS

Patients with preexisting chronic renal insufficiency who achieved their blood pressure control goals were likely to demonstrate an early rise in serum creatinine levels, approximately 25% above the baseline (approximately 1.7 mg/dL) after initiation of ACE inhibitor or ARB therapy. This rise in serum creatinine was more acute (by approximately 15% from the baseline) during the first 2 weeks of therapy and was more gradual (additional approximately 10%) during the third and fourth weeks of therapy (Figure 1). The serum creatinine level was likely to stabilize after about 4 weeks, provided patients had a normal salt and fluid intake. In addition, patients who did not show a rise in serum creatinine level during the first 2 to 4 weeks of therapy, were less likely to experience one after that period, unless they were dehydrated from use of diuretics or gastroenteritis or had used a nonsteroidal antiinflammatory drug (NSAID). In spite of this early rise in serum creatinine in patients with chronic renal insufficiency (a serum creatinine level of >or=124 micromol/L or >or=1.4 mg/dL) who were randomized to receive an ACE inhibitor, these patients receiving the drug showed a 55% to 75% lower risk of worsening renal function than those with normal renal function receiving the drug. The rate of risk reduction was inversely related to the severity of renal impairment at baseline, but data were limited on the benefit of ACE inhibitors in patients with more advanced renal insufficiency (GFR <30 mL/min). The authors noted that those aged 65 and older were likely to have much lower GFRs for given levels of serum creatinine than younger patients and were therefore likely to have advanced renal insufficiency at serum creatinine levels as low as 2 mg/dL (vs 4 mg/dL for younger patients). Patients with normal renal function were likely to show a much smaller rise in serum creatinine level (approximately 10% above the baseline of 0.9 mg/dL), mostly occurring during the first week after initiation of therapy, with subsequent stabilization, whereas patients with normal renal function suffering from heart failure, volume depletion, or bilateral renal artery stenosis experienced a significant rise (approximately 225% above baseline) in serum creatinine level, much higher in magnitude and rate than that experienced by those with renal insufficiency (Figure 1). Serum creatinine levels in these patients sharply increased (by approximately 75% above baseline) in the 2 weeks after the initiation of therapy with an ACE inhibitor, followed by an even sharper increase (another approximately 150%) during the subsequent 2 weeks. Patients with chronic renal insufficiency (serum creatinine>1.5 mg/dL) who received therapy with ACE inhibitors had about a five times higher risk of developing hyperkalemia than those with normal renal function, whereas presence of heart failure increased the risk of hyperkalemia by about three times over those without heart failure. Concomitant use of diuretics was associated with an approximately 60% reduction in risk of hyperkalemia.

CONCLUSION

The authors conclude that, in patients with renal insufficiency (serum creatinine>1.4 mg/dL) treated with ACE inhibitors, there is a strong association between early (within the first 2 months) and moderate (not exceeding 30% over baseline) rise in serum creatinine and slowing of the renal disease progression in the long run. The authors recommend that ACE inhibitor therapy should not be discontinued unless serum creatinine level rise above 30% over baseline during the first 2 months after initiation of therapy or hyperkalemia (serum potassium level >or=5.6 mmol/L) develops.

Underutilisation of ACE inhibitors in patients with congestive heart failure

Congestive heart failure (CHF) is associated with substantial morbidity and mortality, and is the only major cardiovascular disease increasing in prevalence. Despite abundant evidence to support their efficacy and cost-effectiveness, angiotensin-converting enzyme (ACE) inhibitors are sub-optimally used in patients with CHF. This paper reviews the evidence for the sub-optimal use of ACE inhibitors in patients with CHF, the factors contributing to this, and its implications for health systems. A systematic review of all articles assessing practice patterns (specifically the use of ACE inhibitors in CHF) identified by MEDLINE, search of bibliographies, and contact with content experts was undertaken. 37 studies have documented the use of ACE inhibitors in patients with CHF. Studies assessing use among all patients with CHF document 33% to 67% (median 51%) of all patients discharged from hospital and 10% to 36% (median 26%) of community dwelling patients were prescribed ACE inhibitors. Rates of ACE inhibitor use range from 43% to 90% (median of 71%) amongst those discharged from hospital having known systolic dysfunction, and from 67% to 95% (median of 86%) for those monitored in specialty clinics. Moreover, the dosages used in the 'real world' are substantially lower than those proven efficacious in randomised, controlled trials, with evaluations reporting only a minority of patients achieving target doses and/or an overall mean dose achieved to be less than one-half of the target dose. Factors predicting the use and optimal dose administration of ACE inhibitors are identified, and include variables relating to the setting (previous hospitalisation, specialty clinic follow-up), the physician (cardiology specialty versus family practitioner or general internist, board certification), the patient (increased severity of symptoms, male, younger), and the drug (lower frequency of administration). In light of the substantial evidence for reductions in morbidity and mortality, clearly, the prescription of ACE inhibitors is sub-optimal. Wide variability in ACE inhibitor use is noted, with higher rates consistently reported among patients having systolic dysfunction confirmed by an objective assessment--an apparent minority of the those having CHF. Optimisation of the prescription of proven efficacious therapies has the potential to confer a substantial reduction in the total cost of care for patients with CHF by reducing hospitalisations and lengths of hospital stays. It is likely that only multifaceted programs targeted toward the population at large will yield benefits to the healthcare system, given the widespread nature of the sub-optimal prescription of therapies proven effective in the management of patients with CHF.

Potential contributing factors to noncompliance with dietary sodium restriction in patients with heart failure

BACKGROUND

Although sodium restriction is considered essential in the management of patients with chronic heart failure (CHF), there are no data available regarding patients awareness of and ability to comply with the sodium restriction guideline.

METHODS

Between May 1999 and August 2000, 50 patients referred to the Parkland Memorial Hospital CHF clinic were assessed by a registered dietitian for (1) awareness of the sodium restriction guideline, (2) ability to read the sodium content from a Nutrition Facts label, and (3) ability to sort 12 food containers, all bearing a Nutrition Facts label, into high- and low-sodium groups. A global measure of dietary sodium knowledge was calculated ("sodium knowledge score," range 0-10). These tests were repeated after the patient completed one or more educational sessions (mean 2.8 +/- 1.5) with the dietitian.

RESULTS

The proportion of patients aware of the sodium restriction guideline was 14% at baseline and 42% at follow-up (P <.01). The proportion of patients able to read the sodium content from the Nutrition Facts label was 58% at baseline and 92% at follow-up (P <.01). The sodium knowledge score was 3.8 +/- 3.4 at baseline and 5.8 +/- 3.2 at follow-up (P <.01). The proportion of subjects who achieved a perfect sodium knowledge score of 10 was 8% at baseline and 26% at follow-up (P <.05). The number of food containers sorted accurately was 10.6 +/- 1.5 at baseline and 11.3 +/- 1.1 at follow-up, P =.09.

CONCLUSIONS

On referral to a specialty CHF clinic, many patients had severe deficiencies in their knowledge base regarding dietary sodium intake that would preclude compliance with the sodium restriction guideline. Directed education focusing on sodium intake corrected many of these deficiencies.

A survey of the dose of ACE inhibitors prescribed by general physicians for patients with heart failure

AIM

To describe the pattern of angiotensin converting enzyme (ACE) inhibitor doses prescribed by general physicians for patients with chronic heart failure and to review the current evidence favouring the use of higher doses.

DESIGN

A retrospective survey of the medications of 125 patients with chronic heart failure (in both inpatient and outpatient settings) was carried out between December 1999 and February 2000.

RESULTS

Altogether 18.4% of patients surveyed were receiving no ACE inhibitor, the majority of these (65%) having a contraindication to such an agent. Of those patients who were prescribed an ACE inhibitor, 65% were receiving a high dose. The majority of patients who were prescribed a low dose of ACE inhibitor had no identifiable contraindication to receiving a higher dose. Of all patients with chronic heart failure studied, 25% were receiving either no ACE inhibitor or only a low dose in the absence of contraindication.

CONCLUSION

Since no objectively measurable variable has been shown to share a clear relationship with the outcome benefits of ACE inhibitors, no convenient and reliable assessment exists for determining when an adequate dose has been reached for each patient. There is an abundance of evidence favouring high dose ACE inhibitors in heart failure; evidence for the role of low doses is much less clear. The fact that only half of the patients with chronic heart failure were found to be receiving a high dose of ACE inhibitor is probably testimony to inaccurate perceptions and unreliable assumptions among physicians. It is likely that a change in current prescribing patterns would benefit patients with chronic heart failure.

Evaluation of the use of evidence-based angiotensin-converting enzyme inhibitor criteria for the treatment of congestive heart failure: opportunities for pharmacists to improve patient outcomes

BACKGROUND

The under-utilization and under-dosing of angiotensin-converting enzyme inhibitors (ACEIs) in patients with congestive heart failure (CHF) continues to be a problem observed in clinical practice.

OBJECTIVE

To develop and implement drug use evaluation (DUE) criteria for the use of ACEIs in patients with CHF which could be used by pharmacists to ensure that all eligible patients receive an ACEI at an appropriate dose.

METHODS

A retrospective chart review of all patients discharged from the study institution with a diagnosis of CHF during the period of March 1 to July 31, 1998 was conducted using the DUE criteria developed.

RESULTS

Of the 138 patients evaluated, only 68.6% were discharged on ACEI therapy. Additionally, only 40% of those discharged on an ACEI achieved target dose. Multiple regression analysis revealed that males were 2.43 times more likely to be discharged on an ACEI than females, while those on concomitant diuretics or digoxin were less likely to be discharged on an ACEI (25% and 18%, respectively).

CONCLUSIONS

The application of these DUE criteria by pharmacists in hospital and community practice has the potential to improve utilization and dosing of this important class of medications for the management of the symptoms and progression of CHF.

The barriers to effective management of heart failure in general practice

BACKGROUND

Several studies have shown that most patients with heart failure are not investigated and treated according to published guidelines. More effective management could reduce both mortality and morbidity from heart failure.

AIM

To identify the reasons for gaps between recommended and actual management of heart failure in general practice.

DESIGN OF STUDY

A nominal group technique was used to elicit general practitioners' (GPs') perceptions of the reasons for differences between observed and recommended practice.

SETTING

Ten Medical Research Council General Practice Framework practices in the North Thames region.

METHOD

Data were collected on the investigation and treatment of heart failure in the 10 participating practices and presented to 49 GPs and 10 practice nurses from those practices.

RESULTS

Of the 674 patients requiring echocardiograms, 226 were referred for echocardiography (34%), and 183/391 (47%) with probable heart failure were prescribed angiotensin-converting enzyme inhibitors. A wide variety of barriers were elicited. The main barrier to the use of echocardiograms in the diagnosis of heart failure was lack of open access. The main barrier to the use of angiotensin-converting enzyme inhibitors in treating heart failure was GPs' concerns about their possible adverse effects.

CONCLUSION

The barriers to the effective management of heart failure in general practice are complex. We recommend further research to establish whether multifaceted intervention programmes based on our findings can improve the management of heart failure in primary care.

Ambulatory heart failure management in private practice in France

Management of ambulatory heart failure was assessed in a group of 600 patients, mean age 73, 64% males, NYHA I: 9%; II: 52%; III: 33%; IV: 6%; followed up by a representative sample of private cardiologists. Fifty-two percent of patients had been previously hospitalised for worsening heart failure with a mean duration of stay of 13.1 days, for those hospitalised in the year preceding the survey (26%). First diagnosis of heart failure had been performed by a cardiologist (57%), a general practitioner (37%) or another category of physician (6%). Seventy percent of patients received three or more different classes of heart failure medications. Diuretics were prescribed to 71%, angiotensin converting enzyme inhibitors to 54% and digitalis to 35% of the population. Beta-blockers were given to only 14% of the patients. In patients aged over 80 years, only 45% received angiotensin converting enzyme inhibitors.

CONCLUSION

This survey of ambulatory heart failure patients confirms that the disease is predominantly observed in elderly patients, and associated with prolonged and recurrent hospitalisations. The underuse of recommended therapeutic classes including angiotensin converting enzyme inhibitors and beta-blockers deserves further investigation.

Systolic versus diastolic heart failure in community practice: clinical features, outcomes, and the use of angiotensin-converting enzyme inhibitors

BACKGROUND

Among patients with heart failure, there is controversy about whether there are clinical features and laboratory tests that can differentiate patients who have low ejection fractions from those with normal ejection fractions. The usefulness of angiotensin-converting enzyme (ACE) inhibitors among heart failure patients who have normal left ventricular ejection fractions is also not known.

METHODS

From a registry of 2,906 unselected consecutive patients with heart failure who were admitted to 10 acute-care community hospitals during 1995 and 1997, we identified 1291 who had a quantitative measurement of their left ventricular ejection fraction. Patients were separated into three groups based on ejection fraction: < or =0.39 (n = 741, 57%), 0.40 to 0.49 (n = 238, 18%), and > or =0.50 (n = 312, 24%). In-hospital mortality, prescription of ACE inhibitors at discharge, subsequent rehospitalization, quality of life, and survival were measured; survivors were observed for at least 6 months after hospitalization.

RESULTS

The mean (+/- SD) age of the sample was 75+/-11 years; the majority (55%) of patients were women. In multivariate models, age >75 years, female sex, weight >72.7 kg, and a valvular etiology for heart failure were associated with an increased probability of having an ejection fraction > or =0.50; a prior history of heart failure, an ischemic or idiopathic cause of heart failure, and radiographic cardiomegaly were associated with a lower probability of having an ejection fraction > or =0.50. Total mortality was lower in patients with an ejection fraction > or =0.50 than in those with an ejection fraction < or =0.39 (odds ratio [OR] = 0.69, 95% confidence interval [CI 0.49 to 0.98, P = 0.04). Among hospital survivors with an ejection fraction of 0.40 to 0.49, the 65% who were prescribed ACE inhibitors at discharge had better mean adjusted quality-of-life scores (7.0 versus 6.2, P = 0.02), and lower adjusted mortality (OR = 0.34, 95% CI: 0.17 to 0.70, P = 0.01) during follow-up than those who were not prescribed ACE inhibitors. Among hospital survivors with an ejection fraction > or =0.50, the 45% who were prescribed ACE inhibitors at discharge had better (lower) adjusted New York Heart Association (NYHA) functional class (2.1 versus 2.4, P = 0.04) although there was no significant improvement in survival.

CONCLUSIONS

Among patients treated for heart failure in community hospitals, 42% of those whose ejection fraction was measured had a relatively normal systolic function (ejection fraction > or 0.40). The clinical characteristics and mortality of these patients differed from those in patients with low ejection fractions. Among the patients with ejection fractions > or =0.40, the prescription of ACE inhibitors at discharge was associated favorable effects.

The results of a randomized trial of a quality improvement intervention in the care of patients with heart failure. The MISCHF Study Investigators

PURPOSE

Quality improvement and disease management programs for heart failure have improved quality of care and patient outcomes at large tertiary care hospitals. The purpose of this study was to measure the effects of a regional, multihospital, collaborative quality improvement intervention on care and outcomes in heart failure in community hospitals.

PATIENTS AND METHODS

This randomized controlled study included 10 acute care community hospitals in upstate New York. After a baseline period, 5 hospitals were randomly assigned to receive a multifaceted quality improvement intervention (n = 762 patients during the baseline period; n = 840 patients postintervention), while 5 were assigned to a "usual care" control (n = 640 patients during the baseline period; n = 664 patients postintervention). Quality of care was determined using explicit criteria by reviewing the charts of consecutive patients hospitalized with the primary diagnosis of heart failure during the baseline period and again in the postintervention period. Clinical outcomes included hospital length of stay and charges, in-hospital and 6-month mortality, hospital readmission, and quality of life measured after discharge.

RESULTS

Patients had similar characteristics in the baseline and postintervention phases in the intervention and control groups. Using hospital-level analyses, the intervention had mixed effects on 5 quality-of-care markers that were not statistically significant. The mean of the average length of stay among hospitals decreased from 8.0 to 6.2 days in the intervention group, with a smaller decline in mean length of stay in the control group (7.7 to 7.0 days). The net effects of the intervention were nonsignificant changes in length of stay of -1.1 days (95% confidence interval [CI]: -2.9 to 0.7 days, P = 0.18) and in hospital charges of -$817 (95% CI: -$2560 to $926, P = 0.31). There were small and nonsignificant effects on mortality, hospital readmission, and quality of life.

CONCLUSIONS

The incremental effect of regional collaboration among peer community hospitals toward the goal of quality improvement was small and limited to a slightly, but not significantly, shorter length of stay.

Management of heart failure

Heart failure imposes a major burden on society. Primary care physicians, who care for 70% of all heart-failure patients, have opportunities to reduce the economic and mortality impact of this disease by improved outpatient management. Management tasks for these patients are discussed. Successful completion of these tasks will lead to an improvement in functional capacity, fewer hospitalizations, and longer lives for heart-failure patients.

Implementation strategies to manage heart failure outcomes

In the United States, chronic systolic heart failure causes a great economic burden. Pharmacologic and nonpharmacologic therapies must be tailored to the pathophysiologic cause with the ultimate goal of promoting regression or preventing progression of left ventricular remodeling. When this goal is met, symptoms are reduced, quality of life is improved, and morbidity and mortality are decreased. Specific objectives in a nurse-managed heart failure clinic are to improve exercise tolerance, decrease symptoms, and prevent or reduce emergency department visits and acute hospital admissions. Before a nurse-managed outpatient program for heart failure care is implemented, the team must address specific management issues and controversies in heart failure. Actions must focus on chronic disease management rather than just episodic care. Written protocols or algorithms provide guidance in pharmacologic and nonpharmacologic care and ensure that consensus guidelines that offer the best hope of reaching goals are followed.

Nonpharmacologic treatment of heart failure in the elderly

Nonpharmacologic therapy is an integral part of the management of elderly patients with heart failure. Reinforcement of dietary sodium restriction and other nutritional concerns are critical features of therapy. Quality standards for the management of patients with heart failure are being developed, and the implementation of these standards is a goal of clinicians. A multidisciplinary approach to elderly patients with heart failure is beneficial.

The Euro Heart Failure Survey of the EUROHEART survey programme. A survey on the quality of care among patients with heart failure in Europe. The Study Group on Diagnosis of the Working Group on Heart Failure of the European Society of Cardiology. The Medicines Evaluation Group Centre for Health Economics University of York

BACKGROUND

The EUROHEART programme is a rolling programme of cardiovascular surveys among the member nations of the European Society of Cardiology (ESC). These surveys will provide information on the nature of cardiovascular disease and its management. This manuscript describes a survey into the nature and management of heart failure.

AIMS

The EuroHeart Failure survey aims to describe the quality of hospital care, diagnostic and therapeutic, for patients with suspected or confirmed heart failure in ESC member countries. Patients will be interviewed subsequent to hospital discharge to assess their understanding of their condition, side effects from and their compliance with therapy and their satisfaction with the management for heart failure. The quality of management will be judged against the recommendations contained in the ESC guidelines on diagnosis and treatment of heart failure. Outcome will be further assessed by repeat interviews in 6-12 months time. A further survey of heart failure in 2001/2002 is also planned.

METHODS

A prospective survey of all deaths and discharges from medical (cardiology, internal medicine and geriatric medicine) and cardiac surgical wards to identify patients with heart failure, suspected or confirmed. Approximately 70 hospital clusters, comprising two to six hospitals in each cluster, in 24 member countries of the ESC are conducting the study. At the time of writing, approximately 30000 deaths and discharges have been screened and approximately 4000 patients have been enrolled.

CONCLUSIONS

The EuroHeart Survey will allow actual practice to be compared to ESC guidelines on the diagnosis and treatment of heart failure. The surveys and guidelines should prove mutually informative. The main EuroHeart Failure project will be completed by late 2000. However, new centres volunteering to participate in the study (contact corresponding author) may be accepted providing they have the necessary research personnel and provided funding can be agreed for statistical support and administration.