Heart failure patients who are treated in accordance with established European guidelines do better than patients who are not, yet many doctors are still not adhering to the guidelines, according to pioneering research published in Europe’s leading cardiology journal, the European Heart Journal.
In the first large European study to look at the effect of prescribing practices on outcome in heart failure outpatients outside of a clinical trial1, Professor Michel Komajda and colleagues investigated the way that 1,410 patients with mild to moderate heart failure were treated by 150 randomly selected cardiologists or cardiology departments in six European countries (France, Germany, Italy, The Netherlands, Spain and the UK). They measured how closely the patients’ treatment adhered to the guidelines issued by the European Society of Cardiology (ESC).
Prof Komajda, professor of cardiology at the Pitie-Salpetriere Hospital, Paris, France, and a specialist in heart failure, said: “We found that where doctors had treated their patients in accordance with the ESC guidelines, fewer patients had to be referred to the hospital due to deterioration of their heart failure or for cardiovascular symptoms, and there was a longer time before patients had to be readmitted to hospital because of their symptoms.
“However, the study showed that only 60% of patients were treated according to the ESC guidelines with ACE-inhibitors2, beta-blockers or spironolactone3 – the three cardiac drugs for which there is the strongest evidence of benefit – and only 63% of patients were treated according to the guidelines for these three drugs plus the two other commonly used drugs, cardiac glycosides and diuretics.
“This means there is a high proportion of patients who are not receiving the best possible treatment for their condition, and who suffer worsening symptoms and even death as a result.”
Patients in the MAHLER study4 were aged 40 or over, with an average age of nearly 69. They were followed up for six months. The researchers based their assessment of adherence to the ESC guidelines on how closely the patients’ physicians stuck to the ESC recommendations for the use of the five most commonly used cardiac drugs: ACE-inhibitors, beta-blockers, spironolactone, diuretics and cardiac glycosides.
They found that while adherence to diagnosis guidelines was high at 74%, adherence to treatment guidelines was much lower, with large variations between the five different treatments; 85% of patients who needed them were prescribed ACE-inhibitors, 58% were given beta-blockers, 83% a diuretic agent, 52% a cardiac glycoside, and only 36% spironolactone.
When the researchers looked at the impact on outcome of the “big three” drugs (ACE-inhibitors, beta-blockers and spironolactone) they found that amongst patients who were treated with perfect adherence to the guidelines 6.7% and 11.2% were admitted to hospital with chronic heart failure (CHF) or a worsening of their symptoms (CV) respectively; this compared with figures of 9.7% and 15.9% respectively for moderate adherence and 14.7% and 20.6% for low adherence. These outcomes were independent of the severity of the disease, previous hospitalizations for CHF, or the presence of high blood pressure or diabetes.
“We found that adherence to treatment guidelines was independently and strongly correlated to outcome measured by rate of CHF or CV hospitalization and time to CV hospitalization,” said Prof Komajda.
“We hope that these results will encourage cardiologists to ensure that they are familiar with, and adhere to, treatment guidelines. Integrated approaches, including nurses, dieticians, generalists and cardiologists, are needed in order to improve the management of chronic heart failure in clinical practice.”