Implementation of pharmacotherapy guidelines in heart failure: experience from the German Competence Network Heart Failure

Polypharmacy definition and prevalence in heart failure: a systematic review

Polypharmacy and heart failure are becoming increasingly common due to an ageing population and the rise of multimorbidity. Treating heart failure necessitates prescribing of multiple medications, in-line with national and international guidelines predisposing patients to polypharmacy. This review aims to identify how polypharmacy has been defined among heart failure patients in the literature, whether a standard definition in relation to heart failure could be identified and to describe the prevalence. The Healthcare Database Advanced Search (HDAS) was used to search EMBASE, MEDLINE, PubMed, Cinahl and PsychInfo from inception until March 2021. Articles were included of any design, in patients ≥ 18 years old, with a diagnosis of heart failure; that explicitly define and measure polypharmacy. Data were thereafter extracted and described using a narrative synthesis approach. A total of 7522 articles were identified with 22 meeting the inclusion criteria. No standard definition of polypharmacy was identified. The most common definition was that of " ≥ 5 medications." Polypharmacy prevalence was high in heart failure populations, ranging from 17.2 to 99%. Missing or heterogeneous methods for defining heart failure and poor patient cohort characterisation limited the impact of most studies. Polypharmacy, most commonly defined as ≥ 5 medications, is highly prevalent in the heart failure population. There is a need for an internationally agreed definition of polypharmacy, allowing accurate review of polypharmacy issues. Whether an arbitrary numerical cut-off is a suitable definition, rather than medication appropriateness, remains unclear. Further studies are necessary to understand the relationship between polypharmacy with specific types of heart failure and related comorbidities.

Medical therapy doses at hospital discharge in patients with existing and de novo heart failure

AIMS

Uptitrating angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACE-I/ARBs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs) to optimal doses in heart failure with reduced ejection fraction (HFrEF) is associated with improved outcomes and recommended in guidelines. Studies of ambulatory patients found that a minority are prescribed optimal doses. However, dose at hospital discharge has rarely been reported. This information may guide quality improvement initiatives during and following discharge.

METHODS AND RESULTS

We assessed 370 consecutive patients with HFrEF hospitalized at two centres in Vancouver, Canada. Of those without contraindications, 86.4%, 93.4%, and 44.7% were prescribed an ACE-I/ARB/sacubitril-valsartan, beta-blocker, or MRA, respectively. The proportion of eligible patients prescribed target dose was respectively 28.6%, 31.7%, and 4.1%. Forty-two of 248 eligible patients (16.9%) were prescribed ≥50% of target dose, and only three patients received target dosing of all three medication classes. In multivariate regression models, cardiologist involvement in care was independently associated with increased dose and prescription of ≥50% of target dose for all medications, whereas a history of HF was only predictive for beta-blockers.

CONCLUSIONS

In a single-region experience of hospitalized HFrEF patients, a high proportion of eligible patients were discharged on ACE-I/ARB or beta-blocker. Less than half were prescribed MRAs, and few were prescribed ≥50% or target dosing of all medications. Further exploration into barriers to medication uptitration, and improvement in processes of care, is needed.

Percutaneous repair of mitral valve regurgitation in patients with severe heart failure: comparison with optimal medical treatment

BACKGROUND

Occurrence of severe mitral valve (MV) regurgitation (MR) is an independent negative predictor of mortality in patients with severe systolic heart failure (HF). This study examines clinical effects and cardiac reverse remodelling in patients with severe systolic HF receiving percutaneous mitral valve repair (PMVR) using MitraClip in comparison to patients receiving optimal medical therapy only.

METHODS

Between 2010 and 2014, 86 patients (Society of Thoracic Surgeons score: 10.5% ± 1.2%) with severe HF (left ventricular [LV] ejection fraction; LVEF: 25% ± 2%; LV endsystolic diameter [LVESD]: 55 ± 3 mm) and severe MR received PMVR using MitraClip. Cardiac reverse remodelling and clinical parameters were compared to HF patients with severe MR (from our HF outpatient clinic; n = 69; LVEF: 26% ± 1.4%; LVESD: 53 ± 2 mm) receiving optimal medical therapy (OMT) only. All patients received stable OMT and were characterised by echocardiography, 6-minwalk-distance test and cardiac biomarkers within a 24 months observation period.

RESULTS

PMVR in patients with end-stage HF and severe MR resulted in reduction of MR and significant additional cardiac reverse remodelling (LVEF: 26 ± 1.4 vs. 33% ± 2%, p < .05; LVESD: 53 ± 2 vs. 47 ± 2 mm, p < .05) over the 24 months observation period as compared to pharmacologically-only managed comparators.

CONCLUSIONS

Both OMT and PMVR cause cardiac reverse remodelling and relief of symptoms in patients with HF and severe MR. PMVR results in significant additional cardiac reverse remodelling compared to pharmacologically-only managed patients.

A tool for assessment of heart failure prescribing quality: A systematic review and meta-analysis

INTRODUCTION

Heart failure (HF) guidelines aim to standardise patient care. Internationally, prescribing practice in HF may deviate from guidelines and so a standardised tool is required to assess prescribing quality. A systematic review and meta-analysis were performed to identify a quantitative tool for measuring adherence to HF guidelines and its clinical implications.

METHODS

Eleven electronic databases were searched to include studies reporting a comprehensive tool for measuring adherence to prescribing guidelines in HF patients aged ≥18 years. Qualitative studies or studies measuring prescription rates alone were excluded. Study quality was assessed using the Good ReseArch for Comparative Effectiveness Checklist.

RESULTS

In total, 2455 studies were identified. Sixteen eligible full-text articles were included (n = 14 354 patients, mean age 69 ± 8 y). The Guideline Adherence Index (GAI), and its modified versions, was the most frequently cited tool (n = 13). Other tools identified were the Individualised Reconciled Evidence Recommendations, the Composite Heart Failure Performance, and the Heart Failure Scale. The meta-analysis included the GAI studies of good to high quality. The average GAI-3 was 62%. Compared to low GAI, high GAI patients had lower mortality rate (7.6% vs 33.9%) and lower rehospitalisation rates (23.5% vs 24.5%); both P ≤ .05. High GAI was associated with reduced risk of mortality (hazard ratio = 0.29, 95% confidence interval, 0.06-0.51) and rehospitalisation (hazard ratio = 0.64, 95% confidence interval, 0.41-1.00). No tool was used to improve prescribing quality.

CONCLUSION

The GAI is the most frequently used tool to assess guideline adherence in HF. High GAI is associated with improved HF outcomes.

[The telemedical service centre as an essential element of the conceptual approach for telemonitoring of cardiac patients : Requirements on the service, quality, and technical realization of telemonitoring]

Telemonitoring as part of a treatment strategy supports and facilitates the monitoring, disease management and education of patients with heart failure and cardiac arrhythmias. Therefore, telemonitoring affects quality and success of the therapy. Thus, meeting the needs of the patients and of the involved health care professionals is important for the success of the telemonitoring service. Moreover, a high quality of the service has to be ensured. The following article describes several configuration options for telemonitoring services considering technical as well as quality- and service-related aspects.

Treatment of chronic heart failure in Germany: a retrospective database study

Background

Adherence to treatment guidelines affects outcomes in patients with chronic heart failure (HF). We investigated patient pathways and treatment patterns for HF in Germany.

Methods

This retrospective study used anonymous healthcare claims data from the German Health Risk Institute on individuals with statutory health insurance. Patients with uninterrupted data from 1 January 2009 to 31 December 2013 or death (whichever occurred first), and ≥2 recorded HF-related diagnoses in 2011, were included. Patients with newly diagnosed HF were identified. Use of treatment patterns recommended by the European Society of Cardiology (2008) and German Nationale VersorgungsLeitlinien (2011) guidelines was evaluated.

Results

Of 123,925 patients with HF, 21.3% were newly diagnosed. Overall, 63.2% of new HF diagnoses were made in the ambulatory setting; 61.6% of these were made by family practitioners and 14.8% by cardiologists. In the ambulatory setting, family practitioners were primarily responsible for treatment; specialists in internal medicine (70.3% cardiologists) were mainly responsible for performing HF-related technical diagnostics. One-fifth (20.9%) of patients received a New York Heart Association (NYHA) classification; 45.1% of these received a guideline-based treatment pattern. Application of the recommended treatment pattern decreased with advancing disease severity (NYHA class IV: 21.1% application) and older age (≥90 years: 28.3% application).

Conclusions

Family practitioners play a key role in the diagnosis and initial treatment of HF in Germany. A substantial proportion of patients do not receive guideline-recommended pharmacotherapy. These findings should be reflected in the planning of national disease management programmes.

Electronic supplementary material

The online version of this article (doi:10.1007/s00392-017-1138-6) contains supplementary material, which is available to authorized users.

Heart failure in patients with coronary heart disease: Prevalence, characteristics and guideline implementation - Results from the German EuroAspire IV cohort

Background

Adherence to pharmacotherapeutic treatment guidelines in patients with heart failure (HF) is of major prognostic importance, but thorough implementation of guidelines in routine care remains insufficient. Our aim was to investigate prevalence and characteristics of HF in patients with coronary heart disease (CHD), and to assess the adherence to current HF guidelines in patients with HF stage C, thus identifying potential targets for the optimization of guideline implementation.

Methods

Patients from the German sample of the European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EuroAspire) IV survey with a hospitalization for CHD within the previous six to 36 months providing valid data on echocardiography as well as on signs and symptoms of HF were categorized into stages of HF: A, prevalence of risk factors for developing HF; B, asymptomatic but with structural heart disease; C, symptomatic HF. A Guideline Adherence Indicator (GAI-3) was calculated for patients with reduced (≤40%) left ventricular ejection fraction (HFrEF) as number of drugs taken per number of drugs indicated; beta-blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, and mineralocorticoid receptor antagonists (MRA) were considered.

Results

509/536 patients entered analysis. HF stage A was prevalent in n = 20 (3.9%), stage B in n = 264 (51.9%), and stage C in n = 225 (44.2%) patients; 94/225 patients were diagnosed with HFrEF (42%). Stage C patients were older, had a longer duration of CHD, and a higher prevalence of arterial hypertension. Awareness of pre-diagnosed HF was low (19%). Overall GAI-3 of HFrEF patients was 96.4% with a trend towards lower GAI-3 in patients with lower LVEF due to less thorough MRA prescription.

Conclusions

In our sample of CHD patients, prevalence of HF stage C was high and a sizable subgroup suffered from HFrEF. Overall, pharmacotherapy was fairly well implemented in HFrEF patients, although somewhat worse in patients with more reduced ejection fraction. Two major targets were identified possibly suited to further improve the implementation of HF guidelines: 1) increase patients´ awareness of diagnosis and importance of HF; and 2) disseminate knowledge about the importance of appropriately implementing the use of mineralocorticoid receptor antagonists.

Trial registration

This is a cross-sectional analysis of a non-interventional study. Therefore, it was not registered as an interventional trial.

Therapy modifications during hospitalization in patients with chronic heart failure

BACKGROUND

Guidelines on suggested pharmacological treatments for heart failure (HF) are not optimally implemented in clinical practice and whether pharmacotherapy adjustment actually happens in daily practice is largely unknown. We aimed to investigate pharmacotherapy modifications during hospitalization.

METHODS

This was a prospective observational survey where all admissions were screened for HF; 210 patients were included. The guideline adherence index (GAI) and modified GAI (mGAI, if ≥50% of target dose) were used to grade the pharmacotherapy.

RESULTS

Among 198 patients discharged alive (mean age 77years, 51% male), 49% had preserved left ventricular ejection fraction (PLVEF) and 30% had left ventricular systolic dysfunction (LVSD); the echocardiography report was unavailable for 21%. Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists were prescribed to 78%, 58% and 20% of patients on admission and 72%, 65% and 23% at discharge, respectively. Overall, 14% of patients met GAI-3, but at discharge only 7% met mGAI-3. One of the key drugs was stopped or down-titrated in 27%. During follow-up, 21% of patients died (25% with LVSD). Patients with LVSD discharged with at least one HF drug had a lower risk of death than patients with none (HR=0.142, 95% CI=0.029-0.683, p=0.015). Patients with PLVEF had better prognosis than LVSD patients when no HF drugs were prescribed at discharge (HR=0.075, 95% CI=0.009-0.627, p=0.017).

CONCLUSIONS

The pharmacotherapy of HF patients did not improve significantly during hospitalization, remaining suboptimal. Treatment with key drugs was terminated or reduced in a significant proportion of patients, mostly without specific written justification.

Comparison of the Effects of Epicardial and Endocardial Cardiac Resynchronization Therapy on Transmural Dispersion of Repolarization

BACKGROUND

Despite significant improvements in cardiac output and functional capacity with cardiac resynchronization therapy (CRT), incidence of sudden cardiac death still remains high. Reversal of physiological myocardial activation sequence during epicardial pacing increases the transmural dispersion of repolarization (TDR). The aim of this study was to compare the effects of endocardial and epicardial biventricular pacing on repolarization parameters in the same patient group.

METHODS

Seven patients who had transseptal endocardial left ventricle (LV) lead placement, in whom epicardial CRT had failed due to coronary sinus (CS) lead dislodgement after successful implantation, were admitted to the study. LV endocardial leads were implanted through the interatrial septum in a lateral position. Electrocardiograms (ECGs) were scanned before and after successful epicardial and endocardial biventricular pacing and analyzed using digital calipers. ECG markers of TDR (TpTe and TpTe/QT ratio) were measured and compared.

RESULTS

Baseline QRS durations (161.7 ± 15.9 ms vs 162.2 ± 17.8 ms, P = 0.95), TpTe values (107.1 ± 20.5 ms vs 108.5 ± 17.6 ms, P = 0.89), and TpTe/QT ratios (0.24 ± 0.05 vs 0.24 ± 0.03, P = 0.88) were similar before epicardial and endocardial CRT. QRS interval reduction was similar (-28.3 ± 11.6 ms vs -29.1 ± 11.4 ms, P = 0.89) in both groups. Compared to transseptal endocardial CRT, epicardial CRT was associated with a significant increase in TpTe (17.1 ± 19.5 ms vs -12.6 ± 18.9 ms, P = 0.01) and TpTe/QT ratio (0.03 ± 0.04 vs -0.02 ± 0.03, P = 0.04).

CONCLUSION

Transseptal LV endocardial pacing is associated with significant reduction in TDR characteristics compared to epicardial pacing in CRT. Further studies are warranted to determine whether these effects may contribute to reduction of arrhythmias in patients with CRT.

Effects of spironolactone on ventricular-arterial coupling in patients with chronic systolic heart failure and mild symptoms

BACKGROUND

Several studies demonstrated that mineralocorticoid receptor antagonists (MRAs) are able to prevent myocardial and vascular fibrosis, and left ventricular (LV) remodeling in patients with systolic chronic heart failure (HF) and mild symptoms. Ventricular-arterial coupling (VAC) should be influenced by anti-fibrotic interventions. We have assessed the effects of spironolactone on VAC and its components, aortic elastance (Ea) and end-systolic LV elastance (Ees), in patients with HF.

METHODS AND RESULTS

Changes from baseline in VAC were compared between 65 patients treated with spironolactone and 32 controls not receiving MRAs. All patients had HF, reduced LVEF with reduced LV ejection fraction (LVEF) and New York Heart Association (NYHA) functional class I-II symptoms, and underwent transthoracic echocardiography at baseline and after 6 months. VAC was estimated by the modified single-beat method as Ea/Ees. Parameters of LV function improved after 6 month treatment with spironolactone with an increase in the LVEF from 34 ± 8 to 39 ± 8 % (p < 0.001). Spironolactone increased Ees from 1.32 ± 0.38 to 1.57 ± 0.42 mmHg/mL (p < 0.001) and reduced VAC from 2.03 ± 0.59 to 1.66 ± 0.31 (p < 0.001), but did not affect Ea and V0 (LV volume at end-systolic pressure of 0 mmHg). No change in any of these parameters occurred in the control group.

CONCLUSIONS

6-month therapy with spironolactone improved VAC mainly through its effect on Ees in patients with mild HF.

Clinical and echocardiographic correlates of serum copper and zinc in acute and chronic heart failure

AIM

Emerging evidence suggests a pathophysiological role of micronutrient dyshomeostasis in heart failure, including promotion of adverse remodeling and clinical deterioration. We sought to evaluate serum copper (Cu) and zinc (Zn) levels in acute (AHF) and chronic (CHF) heart failure.

METHODS

We studied 125 patients, 71 % male, aged 69 ± 11 years, 37 % with preserved left ventricular ejection fraction (LVEF ≥40 %) (HFPEF), including 81 with AHF and 44 with CHF; 21 healthy volunteers served as controls. Serum Cu and Zn levels were determined using air-acetylene flame atomic absorption spectrophotometry.

RESULTS

Serum Cu levels were significantly higher in AHF (p = 0.006) and CHF (p = 0.002) patients compared to controls after adjusting for age, gender and comorbidities, whereas they did not differ between AHF and CHF (p = 0.840). Additionally, serum Cu in patients with LVEF <40 % was significantly higher compared to both controls (p < 0.001) and HFPEF patients (p = 0.003). Serum Zn was significantly lower in AHF (p < 0.001) and CHF (p = 0.039) compared to control after adjusting for the above-mentioned variables. Moreover, serum Zn was significantly lower in AHF than in CHF (p = 0.015). In multiple linear regression, LVEF (p = 0.033) and E/e ratio (p = 0.006) were independent predictors of serum Cu in total heart failure population, while NYHA class (p < 0.001) and E/e ratio (p = 0.007) were independent predictors of serum Zn.

CONCLUSION

Serum Cu was increased both in AHF and CHF and correlated with LV systolic and diastolic function. Serum Zn, in contrast, was decreased both in AHF and CHF and independently predicted by clinical status and LV diastolic function.

Registry in Germany focusing on level-specific and evidence-based decision finding in the treatment of heart failure: REFLECT-HF

BACKGROUND

In Germany, care for patients with chronic heart failure (HF) is provided by hospital-based cardiologists (HBC), office-based cardiologists (OBC) and general practitioners (GP). We aimed to compare patient characteristics, diagnostic approaches and therapeutic decisions.

METHODS

Multi-centre, cross-sectional, observational survey at 48 physicians. Patients (n = 384) were required to have previously diagnosed HF and NYHA class ≥ II and/or a left ventricular ejection fraction of <50 %. A total of 384 patients were included at 5 HBCs, 26 OBCs and 18 GPs.

RESULTS

A mean of 18.8 % of all patients at HBCs practices had heart failure, compared to a smaller proportion of 13.9 and 6.7 % at OBCs and GPs, respectively. Echo facility was available for all HBCs and OBCs, but for 16.7 % of GPs (p < 0.0001 for trend). Patients at HBCs had a higher NYHA class (65.6 % had class III/IV; p < 0.0001) compared to 36.8 % at OBCs and 39.3 % at GPs. Usage of three guideline-recommended pharmaceutical treatments was more than 80 %: diuretics (83.1 %), renin-angiotensin system blocking agents (91.4 %) and betablockers (90.1 %) with no differences between physician groups. Mineralocorticoid receptor antagonists (MRAs, overall 47.7 %) were more frequently prescribed by OBCs (54.7 %; p = 0.0007 for trend) than HBCs (43.8 %) and GPs (31.0 %). Ivabradin was not frequently used (11.0 % at OBCs, 4.9 % at HBCs and 0 % at GPs; p = 0.0163 for trend). The proportion of patients with CRT (8.6 %), ICD (23.5 %) and CABG (23.1 %) was not statistically different between groups.

CONCLUSION

REFLECT-HF demonstrates that there are some differences in evidence-based treatment decisions between the three main health services (HBC, OBC and GP) providing care for patients with HF in Germany. Advocating adherence to guideline recommendations and earlier adoption of these evidence-based treatments across all levels of care might further improve patient care.

SUrvey of Guideline Adherence for Treatment of Systolic Heart Failure in Real World (SUGAR): a multi-center, retrospective, observational study

BACKGROUND

Clinical practice guidelines have been slowly and inconsistently applied in clinical practice, and certain evidence-based, guideline-driven therapies for heart failure (HF) have been significantly underused. The purpose of this study was to survey guideline compliance and its effect on clinical outcomes in the treatment of systolic HF in Korea.

METHOD AND RESULTS

The SUrvey of Guideline Adherence for Treatment of Systolic Heart Failure in Real World (SUGAR) trial was a multi-center, retrospective, observational study on subjects with systolic HF (ejection fraction <45%) admitted to 23 university hospitals. The guideline adherence indicator (GAI) was defined as a performance measure on the basis of 3 pharmacological classes: angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor II blocker (ARB), beta-blocker (BB), and aldosterone antagonist (AA). Based on the overall adherence percentage, subjects were divided into 2 groups: those with good guideline adherence (GAI ≥50%) and poor guideline adherence (GAI <50%). We included 1319 regional participants as representatives of the standard population from the Korean national census in 2008. Adherence to drugs at discharge was as follows: ACEI or ARB, 89.7%; BB, 69.2%; and AA, 65.9%. Overall, 82.7% of the patients had good guideline adherence. Overall mortality and re-hospitalization rates at 1 year were 6.2% and 37.4%, respectively. Survival analysis by log-rank test showed a significant difference in event-free survival rate of mortality (94.7% vs. 89.8%, p = 0.003) and re-hospitalization (62.3% vs. 56.4%, p = 0.041) between the good and poor guideline-adherence groups.

CONCLUSIONS

Among patients with systolic HF in Korea, adherence to pharmacologic treatment guidelines as determined by performance measures, including prescription of ACEI/ARB and BB at discharge, was associated with improved clinical outcomes.

The effect of placebo adherence on reducing cardiovascular mortality: a meta-analysis

OBJECTIVE

We aim to demonstrate the effect of placebo adherence on reducing CV mortality.

BACKGROUNDS

Good adherence, whether to drug or placebo treatment, is associated with lower CV mortality. However, current evidence for the positive effect of placebo adherence on reducing CV mortality is relatively weak.

METHODS

We conducted a fixed-effect meta-analysis of eight randomized clinical trials to evaluate the effect of placebo adherence on reducing CV mortality. We made a comparison between good placebo adherence and poor drug adherence.

RESULTS

Compared with poor adherence to drug treatment, good adherence to placebo treatment was associated with lower CV mortality (OR = 0.68, 95% CI 0.60-0.77).

CONCLUSION

Good adherence to placebo has a positive effect on reducing CV mortality. The effect of adherence on reducing CV mortality may be independent of the drug effect.

Novel mutations in the sarcomeric protein myopalladin in patients with dilated cardiomyopathy

Recently, missense mutations in titin-associated proteins have been linked to the pathogenesis of dilated cardiomyopathy (DCM). The objective of this study was to search for novel disease-associated mutations in the two human titin-binding proteins myopalladin and its amino-terminal-interacting partner cardiac ankyrin-repeat protein (CARP). In a cohort of 255 cases with familial and sporadic DCM, we analyzed the coding regions and all corresponding intron flanks located in the MYPN and CARP-encoding ANKRD1 gene. Two heterozygous missense mutations were detected in the MYPN gene (p.R955W and p.P961L), but neither of these mutations was found in 300 healthy controls. Both mutations were located in the α-actinin-binding region of myopalladin. Endomyocardial biopsies from the p.R955W carrier showed normal subcellular localization of myopalladin and α-actinin in cardiac myocytes, while their regular sarcomeric staining pattern was significantly disrupted in the p.P961L carrier, indicating that disturbed myofibrillogenesis and altered sarcomere assembly are the cause of the disease. In the ANKRD1 gene, we identified synonymous base exchanges (c.108T>C and c.-79C>T, respectively), but no non-synonymous mutations. In summary, we have identified novel missense mutations in the third immunoglobulin-like domain of myopalladin, which have either no or profound effects on the molecular composition of the sarcomere. According to our epidemiological data, the prevalence of ANKRD1 mutations seems to be lower than that of its binding partner myopalladin, indicating the clinical significance of myopalladin for the functional integrity of the sarcomeric apparatus and the protection against DCM.

Impact of chronic obstructive pulmonary disease severity on symptoms and prognosis in patients with systolic heart failure

BACKGROUND

Systolic heart failure (SHF) and chronic obstructive pulmonary disease (COPD) are frequently associated. The purpose of our study was to explore the impact of COPD severity on symptoms and prognosis in patients with SHF.

METHODS AND RESULTS

Chronic obstructive pulmonary disease was systematically screened by spirometry in 348 patients admitted for SHF from April 2002 to December 2006. Severity of COPD was defined according to the GOLD classification. Prevalence of COPD was 37.9 %. Patients' distribution according to GOLD stages I, II, II and IV were, respectively, 51.5, 37.9, 7.6 and 3.0 %. Severity of dyspnoea increases with GOLD stage. There was a significant correlation between NYHA stage and left ventricular ejection fraction in patients without COPD (R (2) = 0.03; P = 0.01) but not in patients with COPD. Mean follow-up was of 54.9 ± 27.4 months. Mortality was 46.6 % and was highest in the COPD group (53.8 vs. 42.3 %; P = 0.049). Kaplan-Meier survival curves showed that patients with GOLD stage I had the same prognosis than patients without COPD and mortality increased from GOLD stage II to stage IV. After multivariate analysis, GOLD stage and diuretics' dose were independently associated with mortality.

CONCLUSIONS

Chronic obstructive pulmonary disease is frequent in patients with SHF and increases mortality. Since dyspnoea is poorly specific of COPD in chronic heart failure patients, COPD remains underdiagnosed thus leading to inappropriate increase of diuretics' dose. COPD should be systematically screened in patients with SHF to adapt prescription of selective β1-blockers, and diuretics' dose and reduce the exposition to risk factors.