OBJECTIVES: This study evaluated the impact of clinical and physiological factors limiting treatment optimization toward recommended medical therapy in heart failure (HF). BACKGROUND: Although guidelines aim to assist physicians in prescribing evidence-based therapies and to improve outcomes of patients with HF and reduced ejection fraction (HFrEF), gaps in clinical care persist. METHODS: Medical records of all patients with HFrEF followed for at least 6 months at the authors' HF clinic (n = 511) allowed for drug optimization and were reviewed regarding the prescription rates of recommended pharmacological agents and devices (implantable cardioverter-defibrillator [ICD] or cardiac resynchronization therapy [CRT]). Then, an algorithm integrating clinical (New York Heart Association [NYHA] functional class, heart rate, blood pressure and biologic parameters (creatinine, serum potassium) based on the inclusion/exclusion criteria of landmark trials guiding these recommendations) was applied for each agent and device to identify potential explanations for treatment gaps. RESULTS: Gross prescription rates were high for beta-blockers (98.6%), mineralocorticoid receptor antagonist (MRA) (93.4%), vasodilators (90.3%), ICDs (75.1%), and CRT (82.1%) among those eligible, except for ivabradine (46.3%, n = 41). However, achievement of target physiological doses was lower (beta-blockers, 67.5%; MRA, 58.9%; and vasodilators, 63.4%), and one-fifth of patient dosages were still being up-titrated. Suboptimal doses were associated with older age (odds ratio [OR]: 1.221; p < 0.0001) and history of stroke or transient ischemic attack (TIA) (no vs. yes, OR: 0.264; p = 0.0336). CONCLUSIONS: Gaps in adherence to guidelines exist in specialized HF setting and are mostly explained by limiting physiological factors rather than inertia. Older age and history of stroke/TIA, potential markers of frailty, are associated with suboptimal doses of guideline-directed medical therapy, suggesting that an individualized rather than a "one-size-fits-all" approach may be required.
OBJECTIVES: This study evaluated the impact of clinical and physiological factors limiting treatment optimization toward recommended medical therapy in heart failure (HF). BACKGROUND: Although guidelines aim to assist physicians in prescribing evidence-based therapies and to improve outcomes of patients with HF and reduced ejection fraction (HFrEF), gaps in clinical care persist. METHODS: Medical records of all patients with HFrEF followed for at least 6 months at the authors' HF clinic (n = 511) allowed for drug optimization and were reviewed regarding the prescription rates of recommended pharmacological agents and devices (implantable cardioverter-defibrillator [ICD] or cardiac resynchronization therapy [CRT]). Then, an algorithm integrating clinical (New York Heart Association [NYHA] functional class, heart rate, blood pressure and biologic parameters (creatinine, serum potassium) based on the inclusion/exclusion criteria of landmark trials guiding these recommendations) was applied for each agent and device to identify potential explanations for treatment gaps. RESULTS: Gross prescription rates were high for beta-blockers (98.6%), mineralocorticoid receptor antagonist (MRA) (93.4%), vasodilators (90.3%), ICDs (75.1%), and CRT (82.1%) among those eligible, except for ivabradine (46.3%, n = 41). However, achievement of target physiological doses was lower (beta-blockers, 67.5%; MRA, 58.9%; and vasodilators, 63.4%), and one-fifth of patient dosages were still being up-titrated. Suboptimal doses were associated with older age (odds ratio [OR]: 1.221; p < 0.0001) and history of stroke or transient ischemic attack (TIA) (no vs. yes, OR: 0.264; p = 0.0336). CONCLUSIONS: Gaps in adherence to guidelines exist in specialized HF setting and are mostly explained by limiting physiological factors rather than inertia. Older age and history of stroke/TIA, potential markers of frailty, are associated with suboptimal doses of guideline-directed medical therapy, suggesting that an individualized rather than a "one-size-fits-all" approach may be required.
Authors: Samaneh Salimian; Marc W Deyell; Jason G Andrade; Santabhanu Chakrabarti; Matthew T Bennett; Andrew D Krahn; Nathaniel M Hawkins Journal: Heart Rhythm O2 Date: 2021-12-17
Authors: Matteo Pagnesi; Marianna Adamo; Iziah E Sama; Stefan D Anker; John G Cleland; Kenneth Dickstein; Gerasimos S Filippatos; Riccardo M Inciardi; Chim C Lang; Carlo M Lombardi; Leong L Ng; Piotr Ponikowski; Nilesh J Samani; Faiez Zannad; Dirk J van Veldhuisen; Adriaan A Voors; Marco Metra Journal: Clin Res Cardiol Date: 2022-03-16 Impact factor: 6.138
Authors: Stephanie Poon; Benjamin Leis; Laurie Lambert; Kendra MacFarlane; Kim Anderson; Claudia Blais; Catherine Demers; Justin A Ezekowitz; Nathaniel M Hawkins; Douglas S Lee; Gordon Moe; Roopinder K Sandhu; Sean A Virani; Stephen Wilton; Shelley Zieroth; Robert McKelvie Journal: CJC Open Date: 2022-08-12
Authors: Larry A Allen; Grace Venechuk; Colleen K McIlvennan; Robert L Page; Christopher E Knoepke; Laura J Helmkamp; Prateeti Khazanie; Pamela N Peterson; Kenneth Pierce; Geoffrey Harger; Jocelyn S Thompson; Tristan J Dow; Lance Richards; Janice Huang; James R Strader; Katy E Trinkley; David P Kao; David J Magid; Peter M Buttrick; Daniel D Matlock Journal: Circulation Date: 2020-11-17 Impact factor: 29.690
Authors: John R Teerlink; Rafael Diaz; G Michael Felker; John J V McMurray; Marco Metra; Scott D Solomon; Kirkwood F Adams; Inder Anand; Alexandra Arias-Mendoza; Tor Biering-Sørensen; Michael Böhm; Diana Bonderman; John G F Cleland; Ramon Corbalan; Maria G Crespo-Leiro; Ulf Dahlström; Luis E Echeverria Correa; James C Fang; Gerasimos Filippatos; Cândida Fonseca; Eva Goncalvesova; Assen R Goudev; Jonathan G Howlett; David E Lanfear; Mayanna Lund; Peter Macdonald; Vyacheslav Mareev; Shin-Ichi Momomura; Eileen O'Meara; Alexander Parkhomenko; Piotr Ponikowski; Felix J A Ramires; Pranas Serpytis; Karen Sliwa; Jindrich Spinar; Thomas M Suter; Janos Tomcsanyi; Hans Vandekerckhove; Dragos Vinereanu; Adriaan A Voors; Mehmet B Yilmaz; Faiez Zannad; Lucie Sharpsten; Jason C Legg; Siddique A Abbasi; Claire Varin; Fady I Malik; Christopher E Kurtz Journal: Eur J Heart Fail Date: 2020-10-27 Impact factor: 15.534