Physicians' Academy for Cardiovascular Education

Deferring HF therapy increases mortality risk

The mortality risk of deferring optimal medical therapy in heart failure: a systematic comparison against norms for surgical consent and patient information leaflets

Literature - Zaman S, Zaman SS, Scholtes T, et al. - Eur J Heart Fail 2017;19:1401–1409

Main results

Conclusion

Deferral of ACE inhibitors, beta-blockers, and aldosterone antagonists for 1 year carries an absolute mortality risk of around 1% per month, even in patients with low-risk HF. Deferring HF treatment for 1 year carries 18 000 times more risk than the level at which patient information leaflets begin to mention death. Moreover, since clinicians appreciate the magnitude of risk in this context and even overestimate this risk, written informed consent should be used more often to document HF therapy deferral, which may help to focus patients and their clinicians on the importance of maximal early application of life-saving therapy.

Editorial comment

In their editorial article, Böhm, Laufs, Mahfoud, Schirmer and Kindermann, state that ‘Zaman et al. should be applauded for developing an interesting idea and presenting a novel way of examining improvement in the implementation of various therapies.’ They recommend that patient information and informed consent for not implementing a suggested therapy should be further discussed and included in future guidelines, considering not only the no-harm principle when treating patients, but also the possible legal and health-economic implications.

The authors conclude: ‘The challenge posed to our profession by the fact that it is often necessary to risk causing harm in order to obtain therapeutic benefit is an old one. The provocative paper by Zaman et al. reminds us that making non-maleficence a priority can result in therapeutic nihilism that is indeed harmful to patients. The two important principles of non-maleficence and beneficence must be counterbalanced with one another in patient care in a manner that gives due respect to the patient’s autonomy.’

References

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Find this article online at Eur J Heart Fail

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