Improving heart failure patient outcomes utilizing guideline-directed therapy

Burden and predictors of heart failure treatment outcomes in Ethiopia: A systematic review and meta-analysis protocol

BACKGROUND

Heart failure is an important global health problem which is associated with high mortality. Uncontrolled heart failure leads to hospitalization and reduction in quality of life. Therefore, the study aimed to assess the treatment outcome such as improved, death, hospitalization, and self-discharges without improvement and associated factors in heart failure patients admitted to south western Ethiopian hospitals.

METHODS

We will use databases such as PubMed, Science Direct, HINARI, Scopus and Google Scholar. The final systematic review and meta-analysis will contain papers that fulfill the eligible criteria. A systematic data extraction check list will be used to extract the data, and STATA version 14 will be used for the analysis. Heterogeneity is evaluated using the I2 tests and the Cochrane Q test statistic. To examine publication bias, a funnel plot, Egger's weighted regression, and Begg's test are utilized. The sensitivity analysis and subgroup analysis will be done for studies having heterogeneity. The Joanna Briggs institute meta-analysis of statistics assessment and review instrument (JBI- MAStARI) will be used for quality assessment.

DISCUSSION

This protocol is expected to provide adequate evidence on the burden of poor heart failure treatment outcome that includes self-discharge, developing complication and finally leads to death in acute and chronic heart failure patients in Ethiopia. Furthermore, to enrich our estimation, we also intended to assess the associated factors of poor treatment outcome. Therefore, our review will call for government and non-government interventions in reducing the mortality associated with heart failure.

Factors associated with non-use and sub-target dosing of medical therapy for heart failure with reduced ejection fraction

In clinical practice, many patients with heart failure with reduced ejection fraction (HFrEF) are either not prescribed guideline-directed medical therapies for which they are eligible or are prescribed therapies at sub-target doses. The objective of this study was to examine the factors associated with not receiving guideline-directed medical therapies or receiving sub-target doses. We conducted a systematic review of articles published between January 2014 and May 2019 that described dosing patterns and factors associated with non-use and sub-target dosing of HFrEF therapies in clinical practice. Thirty-seven studies were included. The percentages of patients reaching target doses for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, sacubitril/valsartan, beta-blockers, and mineralocorticoid receptor antagonists ranged from 4 to 55%, 11 to 87%, 4 to 60%, and 22 to 80%, respectively. Older age and worsening renal function were associated with non-use and sub-target dosing, lower body mass index was commonly associated with non-use, and hyperkalemia and hypotension were commonly associated with sub-target dosing. In conclusion, several common patient characteristics are associated with non-use and sub-target dosing of medical therapy for HFrEF. These high-risk groups are in particular need of further studies to improve implementation of available medications and to define the role of novel therapies.

Utilization and Dose Optimization of Angiotensin-Converting Enzyme Inhibitors among Heart Failure Patients in Southwest Ethiopia

Background

Optimal use of angiotensin-converting enzyme inhibitors (ACEIs) is crucial to improve the treatment outcome in heart failure patients. However, little is known about the optimal use of ACEIs among heart failure patients in our setting. Therefore, our study aimed to investigate the utilization and optimal dosing of ACEIs and associated factors in heart failure patients.

Method

A cross-sectional study was conducted on randomly selected patients with heart failure between February 2016 and June 2016 at ambulatory care clinic of Jimma University Medical Center, Ethiopia. Data were collected through patient interview and review of medical records. Binary logistic regression analysis was done to identify factors associated with utilization and optimal dosing of ACEIs.

Results

A total of 308 patients were included in the final analysis of this study. The mean (±standard deviation) age of the patients was 52.3 ±15.5 years. Out of the total, 74.7% of the patients were receiving ACEIs. Among the patients who were receiving ACEIs, only 35.7% were taking optimal dose. New York Heart Association (NYHA) class III (Adjusted odds ratio (AOR):0.12, 95% confidence interval (CI):0.02–0.98), valvular heart disease (AOR: 0.27, 95% CI: 0.13-0.56), hypertension (AOR: 5.82, 95% CI: 2.16-15.71), and diabetes mellitus (AOR: 3.84, 95% CI: 1.07-13.86) were significantly associated with the use of ACEIs, whereas age ≥65 (AOR: 2.61, 95%CI: 1.20-5.64), previous hospitalization for heart failure (AOR: 2.08, 95%CI: 1.11-3.92), diuretic use (AOR: 5.60, 95%CI: 2.75-11.40), and dose of furosemide >40mg (AOR: 9.80, 95%CI: 3.00-31.98) were predictors of suboptimal dosing of ACEIs.

Conclusion

Although majority of patients were receiving ACEIs, only about one-third were using optimal dosage. Valvular heart disease and NYHA class III were negatively associated with the use of ACEIs while previous hospitalization for heart failure, old age, diuretic use, and diuretic dose were predictors of suboptimal dosing of ACEIs. Therefore, more effort needs to be done to minimize the potentially modifiable risk factors of suboptimal use of ACEIs therapy in heart failure patients.