Physician adherence to guidelines associated with improved heart failure outcomes

Background

The prescription of evidence-based therapies at appropriate doses, which are recommended by international guidelines, is the most effective way of ensuring that patients receive optimal care [1-4]. However, there is evidence showing that a large proportion of heart failure (HF) patients do not receive evidence-based treatments. For example, it has been reported that only a median of 27% of patients receive all HF therapies for which they are potentially eligible, and that only 42% of HF patients are discharged on angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), beta-blockers and mineralocorticoid receptor antagonists (MRAs) [5].

In this analysis of the international QUALIFY survey, the impact of physicians’ adherence to guideline-recommended classes and doses of HF medications on clinical outcomes was evaluated at a 6-month follow-up. 6669 HF patients with reduced ejection fraction (HFrEF) were categorized as good adherence (23%), moderate adherence (55%) or poor adherence (22%) to 5 classes of medication (ACEIs, ARBs, beta-blockers, MRAs and ivabradine).

Main results

• Patients with a good adherence score were more likely to be Caucasian than Asian (P<0.001), had higher rates of atrial fibrillation/flutter (P<0.001), coronary artery bypass graft (P=0.002), diabetes mellitus (P<0.001), dyslipidemia (P<0.001), history of hypertension (P<0.001), history of asthma or COPD (P<0.001), chronic kidney disease (P<0.001), ≥3 co-morbidities (P<0.001) and higher BMI (P<0.001), systolic blood pressure (SBP, P<0.001) and diastolic blood pressure (DBP, P<0.001).
• A significantly higher proportion of patients with a poor adherence score had a history of cancer (P=0.043).
• The median left ventricular ejection fraction (LVEF) was comparable across all adherence groups (32.2%, 31.6% and 32.3%, respectively, P=0.004).
• In the group with poor adherence scores, significantly fewer patients were prescribed ACEIs (P<0.001), beta-blockers (P<0.001), MRAs (P<0.001), ivabradine (P<0.001), diuretics (P<0.001), anticoagulants (P<0.001) and statins (P<0.001).
• Except for beta-blockers, patients in the good adherence group had highest prescribing levels for the above classes of drugs. Beta-blockers were most commonly prescribed in the moderate adherence group.
• There was also a trend towards greater use of devices in patients in the good adherence group, with significantly more patients having implantable cardioverter-defibrillators (P=0.001).
• A good adherence score at baseline was consistently associated with better clinical outcomes after the 6-month follow-up compared with a moderate or poor adherence score.
• A poor adherence score was associated with significantly higher all-cause mortality compared with a good adherence score (HR 2.21, 95% CI: 1.42–3.44, P=0.001).
• A poor adherence score was also associated with significantly higher cardiovascular (CV) mortality (HR 2.27, 95% CI: 1.36–3.77, P=0.003), HF mortality (HR 2.26, 95% CI: 1.21–4.2, P=0.032), combined HF hospitalization or HF death (HR 1.26, 95% CI: 1.08–1.71, P=0.024) and CV hospitalization or CV death (HR 1.35, 95% CI: 1.08–1.69, P=0.013).
• There was a strong trend between a poor adherence score and HF hospitalization (HR 1.32, 95% CI: 1.04–1.68).

Conclusion

References

Find this article online at Eur J Heart Fail.