Guideline-recommended drugs underused in chronic heart failure

By Will Boggs MD

NEW YORK (Reuters Health) - Medications recommended for chronic heart failure with reduced ejection fraction (HFrEF) continue to be underused, according to findings from the Dutch CHECK-HF Registry.

Physicians' adherence to treatment guidelines strongly predicts heart-failure outcomes, yet previous studies have shown that angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and mineralocorticoid-receptor antagonists (MRAs) are significantly underused in patients with HFrEF.

Dr. Hans-Peter Brunner-La Rocca from Maastricht University Medical Center, in Maastricht, and colleagues used data from the CHECK-HF registry to investigate adherence to drug-therapy guidelines in more than 10,900 patients, including 68% with HFrEF (LVEF <40%), 19% with HF with mid-range LVEF (HFmrEF, 40% to 49%) and 13% who had only semiquantitatively estimated LVEF <50%.

About 80% of patients with HFrEF were treated with loop diuretics, a similar proportion received renin-angiotensin-system (RAS) blockade or beta-blockers, and about half were prescribed MRAs, the researchers report in the January issue of JACC: Heart Failure.

The combination of an RAS inhibitor and beta-blocker was given to 68.6% of patients with HFrEF, 60.6% of those with HFmrEF and 63.1% of those with semiquantitatively measured LVEF.

However, only 39.2% of those with HFrEF, 27.3% of those with HFmrEF and 29.0% of those with semiquantitatively measured LVEF received a combination of RAS blockade, beta-blockade and MRA.

When patients with contraindications to treatment were added to those who were prescribed medications, 92.6% of patients overall had either an ACE inhibitor or an ARB or were unable to tolerate them, compared with 84.3% for beta-blockers and 61.8% for MRAs.

Age had a significant impact on prescription rates in patients with HFrEF: elderly patients were more often prescribed loop diuretics, whereas younger patients were more often prescribed RAS inhibitors, beta-blockers and MRAs.

Most patients who received guideline-recommended medication had doses lower than those recommended, the researchers note.

"Therefore," they conclude, "there is still significant room for (further) improvement of treatment of patients with reduced LVEF, even 30 years after the first study showing that prognosis can be improved in HFrEF."

Dr. Stephen J. Greene from Duke Clinical Research Institute and Duke University School of Medicine, in Durham, North Carolina, who co-authored an accompanying editorial, told Reuters Health by email, "When we compare these findings from the Netherlands to recently published findings from the United States, we see that use of guideline-recommended medications among heart failure patients with reduced ejection fraction is generally lower in the United States. There remains substantial opportunity to improve outpatient heart failure care."

The editorial cites results from the US CHAMP-HF registry which indicate that fewer than 25% of eligible patients are simultaneously treated with any dose of all three classes of heart failure medication, and only 1% are simultaneously treated at guideline-recommended target doses.

"As a field, heart failure is fortunate to have medications proven to help people live longer and feel better," Dr. Greene said. "We must do everything possible to utilize all these available tools so that patients have the best outcomes possible. Given heart failure remains a leading cause of death, hospitalization, and poor quality of life, not using proven medications among eligible patients or not considering opportunities to increase medication dose cannot be taken lightly."

"Identifying the specific barriers to guideline-recommended treatment and developing effective strategies to improve the quality of heart failure medical therapy in real-world practice must be high research priorities," he added.

Dr. Brunner-La Rocca was unavailable for comment.

SOURCE: https://bit.ly/2Rxn24c and https://bit.ly/2FiGfjG

JACC Heart Fail 2019.

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