Amsterdam, The Netherlands –Tuesday 3 September 2013: Drug treatment for chronic heart failure (HF) is acceptable but device implantations are still too low, according to the latest findings of ESC Heart Failure Long-Term Registry. The results were presented at the ESC Congress today by Professor Aldo P. Maggioni (Italy) and also revealed large heterogeneity in treatment for acute HF.
He added: “The ESC Heart Failure Long-Term Registry, which is part of the ESC’s EORP programme2 was established to evaluate how European guidelines on pharmacological and non-pharmacological treatments for HF are adopted in clinical practice. We also collected information on the reasons for failing to give recommended treatments or dosages.”
The ESC Heart Failure Long-Term Registry is a prospective, observational study conducted in 211 cardiology centres of 21 European and Mediterranean countries. From May 2011 to April 2013, 12,440 patients were enrolled, 40.5% with acute HF and 59.5% with chronic HF. The results of the registry are presented for the first time today at ESC Congress 2013 and published simultaneously in the European Journal of Heart Failure.3
In patients hospitalised with acute HF, use of intravenous inotropes and nitrates was not in line with the guideline recommendations. Prescription rates of all recommended oral medications significantly increased at discharge compared to preadmission. Professor Maggioni said: “Treatment recommendations for patients hospitalised with acute AF are largely based on expert opinion, which may explain why adherence is low. But hospitalisation does provide an opportunity to improve prescription of oral medications.”
In ambulatory patients with chronic HF, renin-angiotensin system (RAS) blockers (includes angiotensin converting enzyme [ACE] inhibitors and angiotensin receptor blockers [ARBs]), beta blockers, and mineralocorticoid receptor antagonists (MRAs) were prescribed in 89.2%, 88.9% and 59.3% of cases. But when reasons for non-adherence were considered, real under-treatment occurred in 5.9%, 4.6% and 14.4% of cases. In most cases the reason for non-prescription was a contraindication or documented intolerance.
Less than one-third of patients received the recommended target dosage of these drugs: 29.3% for ACE-inhibitors, 24.1% for ARBs, 17.5% for beta blockers and 30.5% for MRAs. A reason for not achieving the target dosage was reported in almost two-thirds of the remaining cases and included intolerance and ongoing drug uptitration.
Implantation rates of implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy (CRT) devices in ambulatory patients with chronic HF were analysed. The investigators found that ICD and CRT device implantation was not planned, despite being clinically indicated, in 44% and 40% of patients, respectively. The reasons for non-implantation, when clinically indicated, were doctor uncertainties on the indication, patient refusal or logistical/cost issues. Professor Maggioni said: “Device implantation rates are still too low and greater efforts are needed to increase access.”
Professor Maggioni said: “Recommendations in guidelines are referred to as ‘optimal therapy’ but the ESC-HF Pilot showed that many HF patients do not receive recommended drugs and doses.1 Previous studies have not reported the reasons why recommendations are sometimes not followed in clinical practice.”
He added: “The ESC Heart Failure Long-Term Registry, which is part of the ESC’s EORP programme2 was established to evaluate how European guidelines on pharmacological and non-pharmacological treatments for HF are adopted in clinical practice. We also collected information on the reasons for failing to give recommended treatments or dosages.”
The ESC Heart Failure Long-Term Registry is a prospective, observational study conducted in 211 cardiology centres of 21 European and Mediterranean countries. From May 2011 to April 2013, 12,440 patients were enrolled, 40.5% with acute HF and 59.5% with chronic HF. The results of the registry are presented for the first time today at ESC Congress 2013 and published simultaneously in the European Journal of Heart Failure.3
In patients hospitalised with acute HF, use of intravenous inotropes and nitrates was not in line with the guideline recommendations. Prescription rates of all recommended oral medications significantly increased at discharge compared to preadmission. Professor Maggioni said: “Treatment recommendations for patients hospitalised with acute AF are largely based on expert opinion, which may explain why adherence is low. But hospitalisation does provide an opportunity to improve prescription of oral medications.”
In ambulatory patients with chronic HF, renin-angiotensin system (RAS) blockers (includes angiotensin converting enzyme [ACE] inhibitors and angiotensin receptor blockers [ARBs]), beta blockers, and mineralocorticoid receptor antagonists (MRAs) were prescribed in 89.2%, 88.9% and 59.3% of cases. But when reasons for non-adherence were considered, real under-treatment occurred in 5.9%, 4.6% and 14.4% of cases. In most cases the reason for non-prescription was a contraindication or documented intolerance.
Less than one-third of patients received the recommended target dosage of these drugs: 29.3% for ACE-inhibitors, 24.1% for ARBs, 17.5% for beta blockers and 30.5% for MRAs. A reason for not achieving the target dosage was reported in almost two-thirds of the remaining cases and included intolerance and ongoing drug uptitration.
Professor Maggioni said: “When reasons for non-adherence are taken into account, drug treatment of patients with chronic HF complies acceptably with guidelines. Our results suggest that the dosages used in clinical practice may meet patient need and tolerance to drugs.”
Implantation rates of implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy (CRT) devices in ambulatory patients with chronic HF were analysed. The investigators found that ICD and CRT device implantation was not planned, despite being clinically indicated, in 44% and 40% of patients, respectively. The reasons for non-implantation, when clinically indicated, were doctor uncertainties on the indication, patient refusal or logistical/cost issues. Professor Maggioni said: “Device implantation rates are still too low and greater efforts are needed to increase access.”
He concluded: “Our registry reveals patchy adherence to guidelines in acute HF, acceptable use of drug treatments in chronic HF but sub-optimal use of devices. The practicalities of adhering to guidelines in daily clinical practice should be taken into account when guidelines are being written, particularly since failure to comply may have legal consequences in some countries.”
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