Author + information
- aDuke Clinical Research Institute, Durham, North Carolina
- bDivision of Cardiology, Duke University School of Medicine, Durham, North Carolina
- ↵∗Address for correspondence:
Dr. Stephen J. Greene, Duke Clinical Research Institute, 200 Morris Street, Durham, North Carolina 27701.
“I have been impressed with the urgency of doing. Knowing is not enough; we must apply. Being willing is not enough; we must do.”
—Leonardo da Vinci (1)
Heart failure (HF) is frequently compared with cancer since both are potentially progressive illnesses with high mortality. However, the respective cultures of care and public perception surrounding these conditions are markedly different. A diagnosis of cancer is immediately recognized by the patients and families as a potential life-threatening illness that requires immediate action. Irrespective of symptoms, evidence of disease activity or progression (e.g., on imaging or blood tests) may prompt sudden significant escalation in cancer care, including the use of chemotherapy regimens with substantial side effects. This general sense of urgency is ingrained in cancer care delivery, readily accepted by oncology patients, and generally driven by a keen awareness of the benefits of therapy (and the risks of no therapy). In comparison with cancer, the care of HF with reduced ejection fraction (HFrEF) does not elicit the same sense of urgency among patients, families, or clinicians. HF patients and clinicians have been shown to be overly optimistic in their estimates of survival (2). Short-term symptomatic relief is achieved readily using loop diuretics, potentially distracting from use of guideline-directed medical therapies (GDMT) proven to improve survival and quality of life. Likewise, stable symptoms may be misconstrued as low risk, overlooking sudden death as a common mode of death among ambulatory patients. In contrast to oncology, any intermittent feelings of urgency in outpatient HFrEF care are overshadowed by a pervasive sense of clinical inertia. There is a high “energy of activation” for making guideline-directed changes to HFrEF therapy, and generally a low tolerance for any real or perceived side effects of treatment.
In this issue of JACC: Heart Failure, Brunner La-Rocca et al. (3) present the primary results of the CHECK-HF (Chronisch Hartfalen ESC-richtlijn Cardiologische prajtijk Kwaliteitsproject Hartfalen) registry, a cross-sectional program conducted across 34 cardiology practices in the Netherlands from 2013 to 2016. HF patients were eligible regardless of ejection fraction, with the current report focused primarily on the 5,701 patients with HFrEF. Among HFrEF patients, rates of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB) and beta-blocker use were each approximately 80%, whereas the rate of mineralocorticoid receptor antagonist (MRA) use was approximately 55%. Overall, 39% of patients simultaneously received ACEI/ARB, beta-blocker, and MRA therapy, with rates of this simultaneous triple therapy varying from 17% to 76% across sites. Among those treated with medication, the percentages of those who received target dosing were generally modest, ranging from 19% for beta-blockers to 52% for MRA. The investigators also identified multiple patient factors independently associated with use of each medication. Most notable and consistent was the influence of age, with robust associations between older age and lower likelihood of receiving each class of GDMT.
The investigators are to be congratulated for a timely study that provides granular insight into the quality of outpatient HFrEF medical therapy in the Netherlands. Major strengths of the registry include the absence of a requirement for informed consent and the high proportion of total Dutch sites included (i.e., 40%). Both of these features provide a high degree of confidence that these data reflect the country’s real-world contemporary practice. Moreover, aside from laying a foundation for future efforts to improve care and reduce practice variation within the Netherlands, these data provide additional important perspective on how the quality of HFrEF medical therapy compares globally.
Recently, the CHAMP-HF (Change the Management of Patients with Heart Failure) registry provided a sobering update on the status of outpatient HFrEF medical therapy in U.S. clinical practice (4). Among eligible patients across 150 primary care and cardiology practices, rates of ACEI/ARB/angiotensin receptor-neprilysin inhibitor, beta-blocker, and MRA use were only 72%, 67%, and 33%, respectively. When medications were prescribed, they were generally prescribed at lower doses. Perhaps most alarming, <25% of eligible patients were simultaneously treated with any dose of all 3 classes of medication; only 1% were simultaneously treated at guideline-recommended target doses. These disappointing data reaffirmed the urgent need for U.S. efforts to develop and implement strategies to improve the quality of outpatient HFrEF care. However, in the context of the current findings from CHECK-HF, these U.S. findings are even more concerning. The magnitude of the gaps in medication use identified in CHAMP-HF dwarf those seen in the Netherlands (Figure 1). The overall gaps in target dosing were more comparable between the registries (although this did vary by registry and across therapies), but should not offer consolation to U.S. practice in light of the markedly higher rates of eligible U.S. patients who did not receive therapy.
What might explain differences in medication use between CHECK-HF and CHAMP-HF? Review of the respective patient characteristics suggested that differences in patient profiles were not the predominant drivers of treatment differences. New York Heart Association functional class and systolic blood pressure were remarkably similar between programs. Patients with HFrEF in CHECK-HF tended to be slightly older and have slightly worse renal function, making the advantage in medication use over the U.S. even more impressive. The CHAMP-HF analysis did include a minority of HFrEF patients enrolled from primary care clinics (i.e., 15%), but examination of medication use among cardiology clinic patients showed a similar degree of underperformance in the United States compared with the Netherlands (4). In light of the lower likelihood of patient and practice characteristics driving differences between the registries, attention must focus on addressing the culture of clinical inertia in U.S. outpatient HFrEF care (5). Clinicians and patients might overemphasize the possibility of side effects or the added complexity of a change in medical therapy rather than the downstream longer term benefits of improved morbidity and mortality. This sentiment is consistent with the well-described “risk-treatment paradox,” in which patients at greatest need are less likely to receive appropriate therapy (6).
The data from these 2 important registries of HFrEF medical therapy should be both a call to arms and a signal that improvement is indeed possible. Development of effective strategies to improve implementation of GDMT in appropriate patients must be a high research priority. Attempts to use biomarkers such as natriuretic peptides to improve use of GDMT have been mixed, but may point to better ways to optimize care (7,8). Understanding the underlying reasons for medication decisions and the relative contributions of patient preference, clinician discretion, and systems-based barriers would inform the types of quality improvement initiatives expected to be highest yield. However, irrespective of the barriers identified, an intensified sense of urgency among clinicians, patients, and health systems will be critical for overcoming obstacles to guideline-directed care. In the context of 50% 5-year mortality, substantial physical disability and caregiver burden, and enormous health care expenditure, every effort must be made to use all available tools proven to improve outcomes for patients with HFrEF (9,10). Knowing is not enough—we must do.
↵∗ Editorials published in JACC: Heart Failure reflect the views of the authors and do not necessarily represent the views of JACC: Heart Failure or the American College of Cardiology.
Dr. Greene is supported by the National Heart, Lung, and Blood Institute T32 postdoctoral training grant (T32HL069749-14) and a Heart Failure Society of America/Emergency Medicine Foundation Acute Heart Failure Young Investigator Award funded by Novartis; and has received research support from Amgen and Novartis. Dr. Felker has received grants from the National Institutes of Health, the American Heart Association, Amgen, and Merck; and has been a consultant for Amgen, Novartis, Medtronic, Bristol-Myers Squibb, Roche Diagnostics, Alnylam, SC Pharma, EBR Systems, Cytokinetics, Innolife, Myokardia, and Cardionomic.
- 2019 American College of Cardiology Foundation
- ↵BrainyQuote. Leonardo da Vinci quotes. Available at: https://www.brainyquote.com/quotes/leonardo_da_vinci_120052. Accessed November 6, 2018.
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