Practical recommendations for the use of ACE inhibitors, beta-blockers and spironolactone in heart failure: putting guidelines into practice

Screening, diagnosis and treatment of iron deficiency in chronic heart failure: putting the 2016 European Society of Cardiology heart failure guidelines into clinical practice

Iron deficiency is common in patients with chronic heart failure (CHF) and is associated with reduced exercise performance, impaired health-related quality of life and an increased risk of mortality, irrespective of whether or not anaemia is present. Iron deficiency is a serious but treatable condition. Several randomized controlled clinical trials have demonstrated the ability of intravenous (IV) iron, primarily IV ferric carboxymaltose (FCM), to correct iron deficiency in patients with heart failure with reduced ejection fraction (HFrEF), resulting in improvements in exercise performance, CHF symptoms and health-related quality of life. The importance of addressing the issue of iron deficiency in patients with CHF is reflected in the 2016 European Society of Cardiology (ESC) heart failure guidelines, which recognize iron deficiency as an important co-morbidity, independent of anaemia. These guidelines recommend that all newly diagnosed heart failure patients are routinely tested for iron deficiency and that IV FCM should be considered as a treatment option in symptomatic patients with HFrEF and iron deficiency (serum ferritin < 100 µg/L, or ferritin 100-299 µg/L and transferrin saturation < 20%). Despite these specific recommendations, there is still a lack of practical, easy-to-follow advice on how to diagnose and treat iron deficiency in clinical practice. This article is intended to complement the current 2016 ESC heart failure guidelines by providing practical guidance to all health care professionals relating to the procedures for screening, diagnosis and treatment of iron deficiency in patients with CHF.

Renal function monitoring in heart failure - what is the optimal frequency? A narrative review

The second most common cause of hospitalization due to adverse drug reactions in the UK is renal dysfunction due to diuretics, particularly in patients with heart failure, where diuretic therapy is a mainstay of treatment regimens. Therefore, the optimal frequency for monitoring renal function in these patients is an important consideration for preventing renal failure and hospitalization. This review looks at the current evidence for optimal monitoring practices of renal function in patients with heart failure according to national and international guidelines on the management of heart failure (AHA/NICE/ESC/SIGN). Current guidance of renal function monitoring is in large part based on expert opinion, with a lack of clinical studies that have specifically evaluated the optimal frequency of renal function monitoring in patients with heart failure. Furthermore, there is variability between guidelines, and recommendations are typically nonspecific. Safer prescribing of diuretics in combination with other antiheart failure treatments requires better evidence for frequency of renal function monitoring. We suggest developing more personalized monitoring rather than from the current medication-based guidance. Such flexible clinical guidelines could be implemented using intelligent clinical decision support systems. Personalized renal function monitoring would be more effective in preventing renal decline, rather than reacting to it.

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.

Medication management of chronic heart failure in older adults

Heart failure (HF) is a common problem in older adults. Individuals aged 65 years or older are at a higher risk for developing HF, especially diastolic HF or HF with preserved ejection fraction (HFpEF). HF can be seen in up to 20 % of adults aged 85 years or older. In contrast to middle-aged (40-64 years) HF patients, multiple cardiac, non-cardiac and geriatric syndrome co-morbidities are seen in elderly HF patients. Additionally, age-related changes in pharmacokinetics and pharmacodynamics influence medication therapy. Hence, the management of older patients with HF is challenging and treatment should be modified in the light of the above-mentioned conditions. This article discusses the current evidence for medication management in both systolic HF or HF with reduced ejection fraction (HFrEF) and HFpEF, noting, however, the limited data for HFpEF and HFrEF in those 80 years of age or older. The objective of this article is to discuss evidence-based and outcomes-driven pharmacologic management strategies for chronic HF in the older adults for whom functional and other patient-centered outcomes might be more than or as important as clinical outcomes. Optimal management would be expected to help to reduce illness burden, reduce mortality and hospitalizations, and improve function and quality of life.

Effect of a training program for primary care physicians on the optimization of beta-blocker treatment in elderly patients with heart failure

INTRODUCTION AND OBJECTIVES

Underuse of betablockers may contribute to elevated mortality in chronic heart failure. The aim of this study was to determine whether a specific interventional training program for primary care physicians would help optimize the use of beta-blockers in elderly chronic heart failure patients.

METHODS

This randomized comparative study included 627 patients aged 70 years or more who were discharged consecutively from 53 Spanish hospitals with a principal diagnosis of chronic heart failure. In total, 292 health-care centers in the catchment areas of these hospitals were randomly assigned to two groups: one group of 146 centers carried out an interventional training program on beta-blocker use for primary care physicians belonging to the centers assigned to training, and 146 centers served as a control group. The main outcome variable was the percentage of patients who were receiving a beta-blocker at the maximum or maximum tolerated dose 3 months after hospital discharge.

RESULTS

The patients' mean age was 78+/-5 years and 42% were women. There was no difference between the groups in demographic characteristics, clinical care, or treatment at discharge. The percentage of patients who received beta-blockers at the maximum tolerated dose 3 months after discharge was greater in the training group (49% vs. 38%; P=.014). Being treated in the training group was an independent predictor of receiving a beta-blocker at the MTD (odds ratio=2.46; 95% confidence interval, 1.29-4.69; P< .001).

CONCLUSIONS

Implementation of an interventional training program on beta-blocker treatment for primary care physicians improved the use of these medications in elderly chronic heart failure patients.

Angiotensin receptor blocker therapy for heart failure patients: is combination treatment a feasible prospect?

BACKGROUND

The addition of the angiotensin II type 1 receptor blocker (ARB) candesartan to a angiotensin-converting enzyme inhibitor (ACEI) has been associated with improved clinical outcomes in patients with heart failure. However many do not tolerate combination therapy and concerns have been raised regarding excessive neurohormonal inhibition.

HYPOTHESIS

The majority of patients with chronic heart failure are not eligible or do not tolerate combination therapy with an ACEEI and ARB.

METHODS

We prospectively evaluated 115 consecutive patients with heart failure (median age 74 y; 74% males; mean left ventricular ejection fraction 30%) within a district general hospital for eligibility and tolerance to combination therapy using candesartan in addition to recommended doses of an ACEI.

RESULTS

Overall, 109 (95%) were ineligible to initiate candesartan. The most frequent reasons were that, despite best efforts at optimization, 77% of patients were unable to achieve recommended doses of an ACEI, 29% were relatively asymptomatic, 20% had symptomatic hypotension, and 35% were already taking an ARB due to previous ACEI "intolerance." Overall, 6 (5%) of patients satisfied the eligibility criteria of whom 3 (3% of total) were already taking "optimal" doses of an ARB in addition to an ACEI. The remaining 3 patients commenced the titration schedule with candesartan. All 3 patients failed the first titration phase (4 mg once daily) within 2 weeks of initiation, due to the development of hyperkalemia.

CONCLUSIONS

The use of combination therapy with an ARB in addition to recommended doses of ACEI does not appear feasible in patients with heart failure in the general population, as the vast majority are not eligible.

Prescriptions of recommended heart failure medications can be correlated with patient and physician characteristics

BACKGROUND

Translating the findings from heart failure drug trials into clinical practice has been shown to take time. For the generation of a primary care guideline that takes preferences of general practitioners (GPs) and characteristics of their patients into account, it is necessary to identify the associations between patient and physician characteristics with the prescription of the recommended drugs.

METHODS

We searched for patients with chronic heart failure in the electronic patient records of 14 GPs. In multivariate analyses, we examined the prognostic value of patient and physician characteristics for the prescriptions.

RESULTS

In the 708 identified patients with chronic heart failure, prescription rates for angiotensin converting enzyme inhibitors/angiotensin receptor blockers, beta blockers, diuretics, digitalis and aldosterone antagonists were 50%, 39%, 56%, 35%, and 4%, respectively. On the patient level, age, disease severity, comorbidities and concomitant drug intake were differently related to the prescriptions. On the physician level, age, years of clinical experience and organisation of the practice itself played a differentiating role. conclusion: Our study demonstrates associations between patient and physician characteristics with the prescription of the recommended drugs that should be taken into account to translate guideline recommendations for application in general practice.

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.

Clinical decision support software for chronic heart failure

Critical care pathways, protocols, and guidelines have become an everyday feature of clinical practice and represent a distillation of the best available evidence. Chronic heart failure guidelines can be complex, and it is acknowledged that a combination of knowledge and expert advice, in addition to guidelines, is required to optimally treat these patients. This current article describes the potential value of clinical decision support software (CDSS) in the treatment of patients with chronic heart failure and practical aspects of using such a tool. Barriers to implementation of our tool included relatively low computer skills among family physicians and a lack of complexity within CDSS in addressing the wider nonmedical needs of patients. Improving computer skills, integrating CDSS into referral pathways, and requests for investigation may be ways of enhancing the use of this technology.

Leitliniengerechte Therapie der chronischen Herzinsuffizienz

Chronic heart failure may be caused by systolic pump failure and/or impairment of diastolic filling of the ventricles. The standard pharmacotherapy for systolic heart failure includes an ACE inhibitor, betablocker, diuretics and, in patients with severe symptoms, a low dose aldosterone antagonist. An AT1 receptor blocker is indicated for those patients who do not tolerate ACE inhibitors. If patients remain in the functional class NYHA III-IV despite optimal medication and have cardiac dyssynchrony, biventricular pacing may improve the symptoms and prognosis. While evidence-based treatment significantly reduces morbidity and mortality in systolic heart failure, hardly any results from clinical trials are available for diastolic heart failure. Therefore, therapy in patients with diastolic heart failure remains in most cases empirical.

Best practice in primary care pathology: review 6

This sixth best practice review examines four series of common primary care questions in laboratory medicine: (1) laboratory monitoring in hypertension and heart failure abnormalities; (2) markers of inflammatory joint disease; (3) laboratory investigation of chronic diarrhoea; and (4) mumps and chickenpox. The review is presented in question-answer format, referenced for each question series. The recommendations represent a precis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most are consensus based rather than evidence based. They will be updated periodically to take account of new information.

Changes in heart failure medications in patients hospitalised and discharged

BACKGROUND

To date, evidence-based recommendations help doctors to manage patients with heart failure (HF). However, the implementation of these recommendations in primary care is still problematic as beneficial drugs are infrequently prescribed. The aim of the study was to determine whether admission to hospital increases usage of beneficial HF medication and if this usage is maintained directly after discharge.

METHODS

The study was conducted from November 2002 until January 2004. In 77 patients hospitalised with heart failure (HF), the medication prescribed by the referring general practitioner (GP) and drug treatment directed by the hospital physicians was documented. Information regarding the post-discharge (14 d) therapy by the GP was evaluated via a telephone interview. Ejection fraction values, comorbidity and specifics regarding diagnostic or therapeutic intervention were collected by chart review.

RESULTS

When compared to the referring GPs, hospital physicians prescribed more ACE-inhibitors (58.4% vs. 76.6%; p = 0.001) and beta-blockers of proven efficacy in HF (metoprolol, bisoprolol, carvedilol; 58.4% vs. 81.8%). Aldosterone antagonists were also administered more frequently in the hospital setting compared to general practice (14.3% vs. 37.7%). The New York Heart Association classification for heart failure did not influence whether aldosterone antagonists were administered either in primary or secondary care. Fourteen days after discharge, there was no significant discontinuity in discharge medication.

CONCLUSION

Patients suffering from HF were more likely to receive beneficial medication in hospital than prior to admission. The treatment regime then remained stable two weeks after discharge. We suggest that findings on drug continuation in different cardiovascular patients might be considered validated for patients with HF.

Monitoring renal function in hypertension

Several classes of antihypertensive drugs can cause a fall in glomerular filtration rate and a rise in serum potassium and creatinine concentrations. Appropriate monitoring during treatment of hypertension allows potentially serious underlying conditions to be identified and adverse events avoided.

Practical recommendations for the use of ACE inhibitors, beta-blockers, aldosterone antagonists and angiotensin receptor blockers in heart failure: Putting guidelines into practice

Surveys of prescribing patterns in both hospitals and primary care have usually shown delays in translating the evidence from clinical trials of pharmacological agents into clinical practice, thereby denying patients with heart failure (HF) the benefits of drug treatments proven to improve well-being and prolong life. This may be due to unfamiliarity with the evidence-base for these therapies, the clinical guidelines recommending the use of these treatments or both, as well as concerns regarding adverse events. ACE inhibitors have long been the cornerstone of therapy for systolic HF irrespective of aetiology. Recent trials have now shown that treatment with beta-blockers, aldosterone antagonists and angiotensin receptor blockers also leads to substantial improvements in outcome. In order to accelerate the safe uptake of these treatments and to ensure that all eligible patients receive the most appropriate medications, a clear and concise set of clinical recommendations has been prepared by a group of clinicians with practical expertise in the management of HF. The objective of these recommendations is to provide practical guidance for non-specialists, in order to increase the use of evidenced based therapy for HF. These practical recommendations are meant to serve as a supplement to, rather than replacement of, existing HF guidelines.

Clinical decision support software for management of chronic heart failure: development and evaluation

OBJECTIVE

To develop and evaluate clinical decision support software (CDSS) to aid physicians treat patients with chronic heart failure (CHF).

METHODS

The CDSS was developed after discussions with a multidisciplinary panel. Evaluation was performed in three stages over a 6 month period including an editorial check, one-to-one interviews with potential users and educational meetings with general practitioners (GPs), junior doctors and medical students during which the CDSS was assessed in a cross-over design against paper guidelines. Opinions of the CDSS and the computer literacy of the participants were assessed by questionnaire.

RESULTS

There were several changes to the CDSS at various stages of development and evaluation. One-to-one interviews generated extensive qualitative feedback. GPs had lower computer literacy scores than junior doctors and students (both p<0.01). There were small trends when comparing the CDSS with paper guidelines. GPs scored less well (CDSS 75% vs. 80%, p=0.41), while junior doctors and medical students appeared to improve their scores (72%-84%, p=0.32 and 66%-77%, p=0.19, respectively). Most (70%) found the CDSS more useful than the written guidelines.

CONCLUSION

Development of CDSS using guidelines and expert opinion requires a multidisciplinary iterative process of feedback and software adaptation. Barriers to implementation identified include lower computer literacy among GPs, a lack of complexity within CDSS in addressing non-medical needs of patients and a reluctance among medical staff to consult guidelines during patient consultations. Improving computer skills, integrating CDSS into referral pathways and requests for investigations may be ways of enhancing use of this emerging technology.

Effects of bisoprolol treatment for chronic heart failure initiated and followed up by primary care physicians

Primary care physicians prescribe beta-blockers for chronic heart failure infrequently. The aims of the study were to assess the effects of beta-blocker treatment in out-clinic patients with regard to NYHA class and frequency of adverse events. Beta-blocker treatment was initiated and followed up by primary care physicians.

METHODS

Chronic heart failure patients already treated with ACE-inhibitors and diuretics were included. The 24-week follow-up consisted of a titration phase followed by a maintenance phase. The patients received the beta-blocker bisoprolol with an initial dose of 1.25 mg and a maximal dose of 10 mg.

RESULTS

NYHA class II, III and IV had 174, 146, and one patient, respectively. Treatment duration lasted 189+/-73 days with a maximal bisoprolol dose of 7.2+/-3.2 mg. Sixty-one percent of the patients tolerated at least 7.5 mg bisoprolol. The NYHA class improved from 2.4+/-0.5 at baseline to 1.8+/-0.6 at week 24 (P<0.001). At final assessment, 74% of the patients showed an improvement. The number of permanent treatment withdrawals was 57 (17%). Death occurred in six patients and hospitalisation in 38 patients.

CONCLUSIONS

Bisoprolol treatment in patients with chronic heart failure was effectively and safely carried out by primary care physicians.

Management of heart failure in primary care after implementation of the National Service Framework for Coronary Heart Disease: a cross-sectional study

OBJECTIVES

To compare the management of heart failure with the standards set out in the National Service Framework for Coronary Heart Disease.

STUDY DESIGN

A cross-sectional study in 26 general practices, with a combined list size of 256,188, that are members of the Kent, Surrey and Sussex Primary Care Research Network.

METHODS

Information was extracted on the management of 2129 patients with heart failure, of whom 2097 were aged 45 years and over.

RESULTS

The prevalence of heart failure was 8.3 per 1000. Prevalence rates increased with age, from 0.2 per 1000 in people aged under 35 years of age to 125 per 1000 in those aged 85 years and over. Coronary heart disease (present in 47%) was the most common comorbid condition in men with heart failure, whereas hypertension (present in 46%) was the most common condition in women. Recording of cardiovascular risk factors was generally higher in younger patients than in older patients, and in men than in women. Blood pressure (92% of men and 90% of women) and smoking status (84% of men and 77% of women) were generally the best-recorded cardiovascular risk factors. Blood electrolytes were recorded in about 83% of men and 75% of women. Only 17% of men and 11% of women with heart failure had a record of undergoing an echocardiogram. Use of angiotensin-converting enzyme (ACE) inhibitors or antagonists was 76% in men with heart failure and 68% in women; lowest rates were seen in older patients. Uptake of influenza immunization was generally high, at 85% in men and 84% in women.

CONCLUSIONS

The use of ACE inhibitors in patients with heart failure was higher than in some previous studies. However, many patients have no documentation in their computerized medical records of having undergone key investigations, such as echocardiography.

Manipulation of the Renin Angiotensin System in Peripheral Arterial Disease

The Heart Outcomes Prevention Evaluation (HOPE) study has provided evidence for the use of ramipril for secondary cardiac prevention for patients with peripheral arterial disease. Despite this many vascular surgeons and general practitioners are reluctant to prescribe ACE inhibitors in a group of patients perceived to have a high incidence of renal artery stenosis. This review aims to review the pathophysiology of the renin-angiotensin system and make evidence based recommendations for commencing ACE inhibitors as part of a comprehensive delivery of best medical therapy to patients with peripheral arterial disease.

Beta-blocker therapy in patients with heart failure in the urban setting: moving beyond clinical trials

BACKGROUND

Despite their known benefits, beta-blockers (BBL) are not yet widely prescribed for heart failure, especially in the primary care setting. We wanted to identify patient characteristics that could guide primary care physicians in deciding whether they or a cardiologist should initiate BBL. A second objective was to determine the tolerability of BBL in clinical practice.

METHODS

A retrospective chart review was conducted on a consecutive series of 551 patients with systolic dysfunction referred to a heart failure clinic in an urban public hospital. Patient responses to BBL were stratified into three categories: favorable (improvement of left ventricular ejection fraction by serial echocardiography), unfavorable (development of decompensated heart failure), or neither. Tolerability of BBL was assessed by the need to permanently discontinue BBL.

RESULTS

Of 551 patients, 363 (66%) tolerated BBL. Among patients who had BBL initiated in the clinic, 48 had a favorable response, 34 had an unfavorable response, and 57 had neither a favorable or unfavorable response, as defined. A lower systolic blood pressure and higher diuretic dose were associated with development of decompensated heart failure as compared to improvement of ejection fraction.

CONCLUSIONS

A majority of patients with heart failure in an urban public hospital can tolerate BBL. Easily measurable characteristics such as lower systolic blood pressure and higher diuretic dose may assist primary care physicians in triaging patients for referral to cardiologists for beta-blocker initiation.

Mortality and Morbidity Reduction With Candesartan in Patients With Chronic Heart Failure and Left Ventricular Systolic Dysfunction

Background— Patients with symptomatic chronic heart failure (CHF) and reduced left ventricular ejection fraction (LVEF) have a high risk of death and hospitalization for CHF deterioration despite therapies with angiotensin-converting enzyme (ACE) inhibitors, β-blockers, and even an aldosterone antagonist. To determine whether the angiotensin-receptor blocker (ARB) candesartan decreases cardiovascular mortality, morbidity, and all-cause mortality in patients with CHF and depressed LVEF, a prespecified analysis of the combined Candesartan in Heart Failure Assessment of Reduction in Mortality and morbidity (CHARM) low LVEF trials was performed. CHARM is a randomized, double-blind, placebo-controlled, multicenter, international trial program.

Methods and Results— New York Heart Association (NYHA) class II through IV CHF patients with an LVEF of ≤40% were randomized to candesartan or placebo in 2 complementary parallel trials (CHARM-Alternative, for patients who cannot tolerate ACE inhibitors, and CHARM-Added, for patients who were receiving ACE inhibitors). Mortality and morbidity were determined in 4576 low LVEF patients (2289 candesartan and 2287 placebo), titrated as tolerated to a target dose of 32 mg once daily, and observed for 2 to 4 years (median, 40 months). The primary outcome (time to first event by intention to treat) was cardiovascular death or CHF hospitalization for each trial, with all-cause mortality a secondary end point in the pooled analysis of the low LVEF trials. Of the patients in the candesartan group, 817 (35.7%) experienced cardiovascular death or a CHF hospitalization as compared with 944 (41.3%) in the placebo group (HR 0.82; 95% CI 0.74 to 0.90; P <0.001) with reduced risk for both cardiovascular deaths (521 [22.8%] versus 599 [26.2%]; HR 0.84 [95% CI 0.75 to 0.95]; P =0.005) and CHF hospitalizations (516 [22.5%] versus 642 [28.1%]; HR 0.76 [95% CI 0.68 to 0.85]; P <0.001). It is important to note that all-cause mortality also was significantly reduced by candesartan (642 [28.0%] versus 708 [31.0%]; HR 0.88 [95% CI 0.79 to 0.98]; P =0.018). No significant heterogeneity for the beneficial effects of candesartan was found across prespecified and subsequently identified subgroups including treatment with ACE inhibitors, β-blockers, an aldosterone antagonist, or their combinations. The study drug was discontinued because of adverse effects by 23.1% of patients in the candesartan group and 18.8% in the placebo group; the reasons included increased creatinine (7.1% versus 3.5%), hypotension (4.2% versus 2.1%), and hyperkalemia (2.8% versus 0.5%), respectivelyt (all P <0.001).

Conclusion— Candesartan significantly reduces all-cause mortality, cardiovascular death, and heart failure hospitalizations in patients with CHF and LVEF ≤40% when added to standard therapies including ACE inhibitors, β-blockers, and an aldosterone antagonist. Routine monitoring of blood pressure, serum creatinine, and serum potassium is warranted.

Do evidence-based treatments provide incremental benefits to patients with congestive heart failure already receiving angiotensin-converting enzyme inhibitors? A secondary analysis of one-year outcomes from the Assessment of Treatment with Lisinopril and Survival (ATLAS) study

BACKGROUND

In patients with congestive heart failure (CHF), use of submaximal doses of angiotensin-converting enzyme (ACE) inhibitors (ie, low-dose ACE inhibitors) represents usual care in routine clinical practice, whereas high-dose ACE inhibitors, beta-blockers, and digoxin have each been shown to improve outcomes.

OBJECTIVE

We examined whether treatment with high dose-ACE inhibitors, beta-blockers, and digoxin would each provide incremental benefits over that achieved with usual care and whether concurrent use of high-dose ACE inhibitors, beta-blockers, and digoxin would provide maximal benefits.

METHODS

We conducted a secondary analysis of a randomized, controlled, active-comparator trial. Specifically, we studied 1-year outcomes data from the Assessment of Treatment with Lisinopril and Survival trial (ATLAS), which assessed high-dose ACE inhibitors (mean dosage, 33.2 mg daily lisinopril) versus low-dose ACE inhibitors (mean dosage, 4.5 mg daily lisinopril) in patients of any age with advanced CHF in 287 centers in 19 countries in the 1990s. In our analysis, patients were classified by their use of low-dose or high-dose ACE inhibitors, beta-blockers, and/or digoxin at the time of randomization. The primary outcome of interest was the ATLAS composite end point of all-cause mortality or hospitalization for any reason at 1 year. Multiple logistic regression analyses were used to adjust for baseline differences in patient characteristics.

RESULTS

The 3164 patients in the ATLAS study had a mean (SD) age of 64 (10) years; 2516 patients (80%) were men and 648 (20%) were women; mean (SD) left-ventricular ejection fraction was 23% (6%); and 2671 patients (84%) had New York Heart Association class III or IV symptoms. At 1 year, the mortality rate was 13% (408 patients); 43% (1369 patients) had > or =1 hospitalization; and the composite end point of mortality or hospitalization was 47% (1489 patients). Most patients (2873; 91%) remained on their initial treatment regimen. Compared with low-dose ACE inhibitors (n = 471), the composite end point decreased incrementally with the use of high-dose ACE inhibitors (n = 475) (adjusted odds ratio [aOR], 0.93; P = NS), high-dose ACE inhibitors plus beta-blockers (n = 72) (aOR, 0.89; P = NS), and high-dose ACE inhibitors plus beta-blockers plus digoxin (n = 77) (aOR, 0.47; P = 0.006). In absolute proportions, patients receiving high-dose ACE inhibitors plus beta-blockers plus digoxin for 1 year had 12% fewer deaths and hospitalizations than patients receiving low-dose ACE inhibitors alone.

CONCLUSIONS

Compared with usual care for patients with CHF, in this analysis, an evidence-based strategy that incorporated high-dose ACE inhibitors plus beta-blockers plus digoxin was associated with incrementally greater reductions in morbidity and mortality. These findings support treatment guidelines that recommend the concurrent use of all available proven efficacious treatment in patients with advanced CHF.

Drug therapy in chronic heart failure

Chronic heart failure is widely recognised as a common and escalating problem that causes major disability and often shortens life. Diuretics and digoxin have formed the mainstay of treatment for many years. Clinical trials have demonstrated that angiotensin converting enzymes and beta-blockers, in selected patients, improve symptoms and reduce mortality. Angiotensin-II antagonists and spironolactone may also have a role in certain individuals. Newer pharmacological approaches to the management of this complex disease are being developed, but await full evaluation.

Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers: what we know and current controversies

A little more than a decade ago, management of heart failure was changed forever when a number of randomized clinical trials confirmed that a class of drugs, angiotensin-converting enzyme (ACE) inhibitors, could improve survival in patients with heart failure. The recognition that blockade of one of the neurohumoral systems activated in heart failure could improve outcomes prompted widespread testing of other neurohumoral blockers, such as beta-adrenergic blocking agents, aldosterone antagonists, and most recently, angiotensin II type 1 receptor blockers (ARBs) for the treatment of heart failure. This article describes what is known about the use of ACE inhibitors and ARBs in the management of heart failure and presents the current controversies surrounding the use of these agents.

Carnitine palmitoyltransferase-I, a new target for the treatment of heart failure: perspectives on a shift in myocardial metabolism as a therapeutic intervention

Although the heart is capable of extracting energy from different types of substrates such as fatty acids and carbohydrates, fatty acids are the preferred fuel under physiological conditions. In view of the presence of diverse defects in myocardial metabolism in the failing heart, changes in metabolism of glucose and fatty acids are considered as viable targets for therapeutic modification in the treatment of heart failure. One of these changes involves the carnitine palmitoyltransferase (CPT) enzymes, which are required for the transfer of long chain fatty acids into the mitochondrial matrix for oxidation. Since CPT inhibitors have been shown to prevent the undesirable effects induced by mechanical overload, e.g. cardiac hypertrophy and heart failure, it was considered of interest to examine whether the inhibition of CPT enzymes represents a novel approach for the treatment of heart disease. A shift from fatty acid metabolism to glucose metabolism due to CPT-I inhibition has been reported to exert beneficial effects in both cardiac hypertrophy and heart failure. Since the inhibition of fatty acid oxidation is effective in controlling abnormalities in diabetes mellitus, CPT-I inhibitors may also prove useful in the treatment of diabetic cardiomyopathy. Accordingly, it is suggested that CPT-I may be a potential target for drug development for the therapy of heart disease in general and heart failure in particular.

Specialist nurse supervised in-hospital titration to target dose ACE inhibitor--is it safe and feasible in a community heart failure population?

BACKGROUND

Recently published guidelines from the ESC and practical recommendations from an international group of experts support the up-titration of ACE inhibitors at 1- to 2-week intervals. Observance of these guidelines could contribute to the under-dosing of ACE inhibitors at discharge in patients admitted with heart failure. Specialist heart failure nurse supervision of ACE inhibitor titration during the in-hospital stay could be a safe and effective means of avoiding this problem.

OBJECTIVE

This observational study examines the feasibility of specialist heart failure nurse supervised rapid titration of ACE inhibition to at least target dose in sequential, class IV heart failure patients admitted to the cardiology service with left ventricular failure and not previously treated with an ACE inhibitor.

METHODS

Fifty-two patients (mean age 71.9+/-11.6 years) were initiated on perindopril and titrated to maximally tolerated dose during the in-hospital phase. Indices of renal function (creatinine, urea, potassium) and systolic blood pressure were observed at baseline and at discharge from hospital and at 3 months. Lengths of stay and titration intervals were recorded.

RESULTS

The mean length of stay was 10.3+/-7.7 days and 98% of patients achieved at least target dose of perindopril before discharge. The average time to titration to final dose was 5.5+/-4.2 days. Systolic blood pressure decreased significantly from 132+/-28 mmHg on admission to 117+/-18 mmHg on discharge. Mean baseline urea, creatinine and potassium did not change from admission to discharge (urea 8.4+/-2.5 to 9.2+/-3.9 mmol/l, P=0.15; creatinine 122.7+/-30.3 to 122.4+/-35.4 micromol/l, P=0.93; potassium 4.0+/-0.5 to 4.0+/-0.3 mEq/l, P=0.86). No significant changes were observed in these parameters at 12 weeks. There were no recorded incidences of symptomatic hypotension or progressive renal dysfunction even in patients (n=25) with evidence of chronic renal impairment (creatinine >120 micromol/l).

CONCLUSIONS

Specialist heart failure nurse supervised initiation and rapid in-hospital titration of ACE inhibitor to at least target dose is feasible and safe in a severe heart failure population admitted with class IV heart failure. Routine application of this approach may help avoid under-dosing of ACE inhibitors without increasing length of hospital stay, and may reduce outpatient visits to heart failure clinics for titration.

Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial

BACKGROUND

Angiotensin II type 1 receptor blockers have favourable effects on haemodynamic measurements, neurohumoral activity, and left-ventricular remodelling when added to angiotensin-converting-enzyme (ACE) inhibitors in patients with chronic heart failure (CHF). We aimed to find out whether these drugs improve clinical outcome.

METHODS

Between March, 1999, and November, 1999, we enrolled 2548 patients with New York Heart Association functional class II-IV CHF and left-ventricular ejection fraction 40% or lower, and who were being treated with ACE inhibitors. We randomly assigned patients candesartan (n=1276, target dose 32 mg once daily) or placebo (n=1272). At baseline, 55% of patients were also treated with beta blockers and 17% with spironolactone. The primary outcome of the study was the composite of cardiovascular death or hospital admission for CHF. Analysis was done by intention to treat.

FINDINGS

The median follow-up was 41 months. 483 (38%) patients in the candesartan group and 538 (42%) in the placebo group experienced the primary outcome (unadjusted hazard ratio 0.85 [95% CI 0.75-0.96], p=0.011; covariate adjusted p=0.010). Candesartan reduced each of the components of the primary outcome significantly, as well as the total number of hospital admissions for CHF. The benefits of candesartan were similar in all predefined subgroups, including patients receiving baseline beta blocker treatment.

INTERPRETATION

The addition of candesartan to ACE inhibitor and other treatment leads to a further clinically important reduction in relevant cardiovascular events in patients with CHF and reduced left-ventricular ejection fraction.

The safety of spironolactone treatment in patients with heart failure

INTRODUCTION

Spironolactone is increasingly being used in the treatment of heart failure. However, it has been associated with cases of hyperkalaemia. The common use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin-2 receptor (AT2) antagonists in heart failure increases the risk of hyperkalaemia.

OBJECTIVE

To identify the risk of spironolactone withdrawal, hyperkalaemia and severe hyperkalaemia in patients prescribed spironolactone together with either an ACE inhibitor or an AT2 antagonist.

METHODS

Retrospective identification and analysis of patients co-prescribed an ACE inhibitor or an AT2 antagonist with spironolactone. Patients' records were linked to their biochemical results and the doses of spironolactone, ACE inhibitor and AT2 antagonists received by them.

RESULTS

We found that a higher proportion of patients in our cohort stopped taking spironolactone compared with the Randomised Aldactone Evaluation Study and a higher proportion developed hyperkalaemia, a predicted adverse effect of spironolactone combination with an ACE inhibitor or an AT2 antagonist. Patients with diabetes mellitus and those with a haematocrit below 0.36, were more likely to develop hyperkalaemia than those without these traits.

CONCLUSIONS

Spironolactone is a common cause of hyperkalaemia when used in combination with either an ACE inhibitor or an AT2 antagonist. This reinforces the need for care when extrapolating the results of clinical trials to daily clinical practice.

[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.

Trends in prescribing for heart failure in Dutch primary care from 1996 to 2000

PURPOSE

The aim of this study is to explore trends in primary care prescribing for chronic heart failure (CHF) over a 5-year period (1996-2000).

METHODS

This study consisted of repeated cross-sectional surveys in a dynamic cohort from the Integrated Primary Care Information (IPCI) primary care database. The cohort comprised all patients aged > or = 55 years with a CHF diagnosis and prescribed a cardiovascular medication during the study period. The point prevalence per calendar year was determined for each of the main drug groups used to treat CHF.

RESULTS

The study population consisted of 3121 CHF patients. Small increases were seen in the percentage of CHF patients prescribed spironolactone (4.6%, 95% CI: 2.3-6.9%), beta-blockers (6.1%, 95% CI: 2.6-9.5%) and angiotensin II antagonists (6.8%, 95% CI: 5.1-8.6%) during the study period, while the prescribing of digoxin decreased (-4.4%, 95% CI: -8.2 to -0.7). Prescribing of diuretics (difference: -0.7% 95% CI: -2.7-4.2) and ACE inhibitors (difference: 4.0% 95% CI: -0.1-8.2%) remained unchanged.

CONCLUSIONS

Prescription of some drug groups for CHF increased. However, given the new scientific evidence that has emerged in past 15 years regarding CHF pharmacotherapy, the changes observed were less than expected.

Use of carvedilol in the treatment of heart failure

Carvedilol is a multiple action, non-specific, adrenergic beta-blocker, licensed for the treatment of mild, moderate and severe chronic heart failure. This article considers the evidence for using beta-blockers in general, and carvedilol in particular, in the treatment of heart failure. Evidence suggests that carvedilol should be considered as an alternative first-line initiation therapy.

Bisoprolol: a review of its use in chronic heart failure

Bisoprolol is a highly selective beta(1)-adrenoceptor antagonist. Administration of bisoprolol to patients with chronic heart failure is associated with increases in left ventricular function and reductions in heart rate; increases in heart rate variability are also seen. Two major randomised, double-blind, placebo-controlled, multicentre trials have examined the clinical efficacy of bisoprolol in combination with ACE inhibitors and diuretics in patients with stable chronic heart failure (New York Heart Association class III or IV): the Cardiac Insufficiency Bisoprolol Study (CIBIS; n = 641) and CIBIS II (n = 2 647). All-cause mortality (primary endpoint) was significantly lower in bisoprolol than in placebo recipients in CIBIS II (11.8 vs 17.3%) and was reduced by bisoprolol regardless of dosage. All-cause mortality was also lower in CIBIS (16.6 vs 20.9%) although the difference did not achieve statistical significance. In a meta-analysis of CIBIS and CIBIS II (n = 3 288), a relative reduction of 29% in the incidence of all-cause mortality was seen in bisoprolol versus placebo recipients; this analysis also demonstrated that bisoprolol reduces mortality in patients with chronic heart failure regardless of aetiology or severity. In CIBIS II, there were significantly fewer cardiovascular deaths, admissions to hospital for any reason, or cardiovascular deaths or cardiovascular hospitalisations (combined endpoint) in bisoprolol, compared with placebo, recipients (secondary endpoints). Compared with standard treatment alone, the addition of bisoprolol was a cost-effective option in chronic heart failure in UK, French, German and Swedish pharmacoeconomic studies. Bisoprolol is generally well tolerated in patients with chronic heart failure. In CIBIS II, adverse events occurring more commonly in bisoprolol than placebo recipients, regardless of causal relationship with the study medication, included dizziness, bradycardia, hypotension and fatigue. Bisoprolol recipients were less likely than placebo recipients to experience worsening of heart failure, dyspnoea or tachycardia. In both CIBIS and CIBIS II there was no significant difference between bisoprolol and placebo recipients in the incidence of permanent treatment withdrawal. In conclusion, adding the highly selective beta(1)-blocker bisoprolol to a treatment regimen comprising an ACE inhibitor and a diuretic significantly improves survival in patients with stable chronic heart failure and reduces the need for hospitalisation. The use of bisoprolol in this disorder is generally well tolerated and is cost effective. Thus, bisoprolol should be considered a standard treatment option when selecting a beta-blocker for use in combination with ACE inhibitors and diuretics in patients with stable, moderate to severe chronic heart failure.

Cost-effectiveness of spironolactone in patients with severe heart failure

BACKGROUND

Management of heart failure is estimated to consume between 1% and 2% of total healthcare resources with hospital admissions accounting for up to 70% of this. The ability of the aldosterone antagonist spironolactone to reduce hospital admission rates by 35% would be expected to prove cost-effective.

AIM

To determine the cost-effectiveness of spironolactone when added to standard therapy in patients with severe chronic heart failure.

METHODS

A Markov model of chronic heart failure was constructed using Treeage software. Irish cost data were incorporated into the model.

RESULTS

The incremental cost-effectiveness ratio (ICER) for spironolactone therapy was Euro 466 per life year gained (LYG). Sensitivity analysis demonstrated an ICER range of Euro 75 to Euro 1,136 per LYG.

CONCLUSION

This economic evaluation suggests that the addition of spironolactone to standard therapy for patients with severe chronic heart failure is not only safe and effective, but is highly cost-effective in the Irish healthcare setting.