The AHCPR clinical practice guideline for heart failure revisited

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.

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.

[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.

Pharmacotherapy of systolic heart failure: a review of recent literature and practical applications

Since the publication of the Agency for Health Care Policy and Research Guidelines for treatment of heart failure, a number of new agents have been investigated for this indication. beta-Blockers have now been shown to improve outcomes in mild to moderate heart failure when added to standard therapy. Angiotensin II receptor antagonists have also been investigated and show promise. In general, calcium channel blockers are second- or third-line agents in patients refractory to other therapy. Investigational agents including spironolactone may also hold promise for future therapy.

Therapeutic range of digoxin's efficacy in heart failure: what is the evidence?

Clinical studies have solidified the utility of digoxin in patients with left ventricular dysfunction and normal sinus rhythm. No definitive data have been published to clarify the range of serum digoxin concentrations associated with clinical benefit. The traditional therapeutic range of 0.8-2.0 ng/ml was developed originally to classify digoxin toxicity, not efficacy. In addition, this reference range was used before publication of the Digitalis Investigators Group trial. Clinical and neurohormonal studies have attempted to characterize serum concentrations that are associated with clinical efficacy.