Article

Adherence to guidelines is a predictor of outcome in chronic heart failure: the MAHLER survey

University of Cologne, Köln, North Rhine-Westphalia, Germany
European Heart Journal (Impact Factor: 14.72). 08/2005; 26(16):1653-9. DOI: 10.1093/eurheartj/ehi251
Source: PubMed

ABSTRACT The impact on outcome of the implementation of European guidelines for the treatment of chronic heart failure (CHF) has not been evaluated. We investigated the consequences of adherence to care by cardiologists on the rate of CHF and cardiovascular (CV) hospitalizations and time to CV hospitalization.
We constructed class adherence indicators for angiotensin-converting enzyme (ACE)-inhibitors, beta-blockers, spironolactone, diuretics, and cardiac glycosides and GAIs (GAI3 adherence to first three classes of heart failure medication, GAI5 adherence to five classes). In the study, 1410 evaluable patients (mean age 69, 69% males, New York Heart Association (NYHA) II: 64%, III: 34%, IV: 2%) were enrolled and followed up for 6 months by 150 randomly selected cardiologists/cardiology departments from six European countries (France, Germany, Italy, The Netherlands, Spain, and UK). Overall, adherence to treatment guidelines was 60 (GAI3) and 63% (GAI5) and was better for ACE-I (88%) or diuretics (82%) than for cardiac glycosides (52%), beta-blockers (58%), and spironolactone (36%). In the three tertiles of the population defined by a decreasing mean adherence score value, CHF and CV hospitalization rates were, respectively, 6.7, 9.7, and 14.7% and 11.2, 15.9, and 20.6% (P<0.002 and P<0.001, respectively). Global adherence indicator GAI3 was an independent predictor of time to CV hospitalization in a multi-variable model together with NYHA Class, history of CHF hospitalization, ischaemic aetiology, diabetes mellitus, and hypertension.
We demonstrate that adherence of physicians to treatment guidelines is a strong predictor of fewer CV hospitalizations in actual practice. There is a need to develop further quality improvement programmes in this condition.

Download full-text

Full-text

Available from: Pablo Lapuerta, Jul 02, 2015
0 Followers
 · 
143 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Current therapeutic guidelines for chronic heart failure (HF) recommend high (if possible, maximum) target doses of angiotensin-converting enzyme (ACE) inhibitors and beta-blockers. This is based on "evidence" from large-scale trials in selected patient populations. In "real life", however, many patients receive doses below defined targets, which is usually classified as "under-treatment". When considering whether everyday practice is suboptimal, an important question arises: is more always better and should dosage recommendations be followed in all patients? The superiority of high vs. low-to-moderate doses of ACE inhibitors and beta-blockers in reducing mortality from chronic HF has not been documented convincingly. In large trials with beta-blockers, the efficacy of below-target doses was not significantly different from that of high doses. With high-dose lisinopril, a reduction in the rate of hospitalizations was achieved at the cost of more adverse events. A combination of ACE inhibitors and angiotensin receptor blockers in chronic HF may also cause more problems than benefits. The risks of high doses of spironolactone, digoxin and diuretics are well-known. Sicker elderly and multimorbid patients often do not tolerate the recommended targets but can still have a good clinical response with an improved outcome at lower doses. Therefore lower-than-target doses may not necessarily be wrong in certain patients and are better than "no doses", for example, failure to prescribe essential heart-failure drugs. Individualized doses of ACE inhibitors and beta-blockers (best in combination) are indicated in most patients with chronic HF. Less rigid application of guideline recommendations may improve their acceptance.
    Archives of cardiovascular diseases 11/2009; 102(11):785-9. DOI:10.1016/j.acvd.2009.08.011 · 1.66 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Several surveys show that patients with chronic heart failure (CHF) are sub-optimally managed and treatment guidelines are not implemented in clinical practice. To investigate awareness and perceptions of the 2005 European Society of Cardiology (ESC) guidelines for CHF. 467 cardiologists from seven European countries completed an on-line interview using a validated, semi-structured questionnaire including questions about awareness and relevance of CHF guidelines. To assess agreement with ESC guidelines, three fictitious patient cases were presented and respondents' management choices compared with those of an expert panel based on the guidelines. Awareness of CHF guidelines was high, with 98% aware of any guideline and 65% aware of ESC guidelines. ESC guidelines were considered relevant (51%) or very relevant (38%) for guiding treatment decisions. Up to 92% of respondents perceived that they adhered to the ESC guidelines. For the patient cases, <or=25% made treatment recommendations that completely matched those formulated by the expert panel. Respondents considered patient compliance (52%) and guideline complexity (46%) major barriers to implementation. Cardiologists reported high awareness of and a positive attitude towards ESC CHF guidelines. Provision of guidelines in a concise and accessible format is perceived as a key factor to improve implementation.
    European Journal of Heart Failure 10/2008; 10(10):1020-5. DOI:10.1016/j.ejheart.2008.08.001 · 6.58 Impact Factor
  • Source
    European Journal of Heart Failure 05/2008; 10(4):331-3. DOI:10.1016/j.ejheart.2008.02.017 · 6.58 Impact Factor