Author + information
- Received November 19, 2019
- Revision received April 13, 2020
- Accepted April 30, 2020
- Published online August 31, 2020.
- Marilyne Jarjour, MSca,
- Christine Henri, MDa,
- Simon de Denus, BPharm, PhDa,
- Annik Fortier, MScb,
- Nadia Bouabdallaoui, MD, PhD(c)a,
- Anil Nigam, MDa,
- Eileen O’Meara, MDa,
- Charaf Ahnadi, PhDc,
- Michel White, MDa,
- Patrick Garceau, MDa,
- Normand Racine, MDa,
- Marie-Claude Parent, MDa,
- Mark Liszkowski, MDa,
- Geneviève Giraldeau, MDa,
- Jean-Lucien Rouleau, MDa and
- Anique Ducharme, MD, MSca,∗ ()
- aDepartment of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
- bBiostatistics, Montreal Health Innovation Coordinating Center, Montreal, Quebec, Canada
- cCollaborative Research for Effective Diagnostics, University Hospital Center of Sherbrooke, Sherbrooke, Quebec, Canada
- ↵∗Address for correspondence:
Dr. Anique Ducharme, Montreal Heart Institute, Research Center (S-2700), 5000 Belanger Street, Montreal, Quebec H1T 1C8, Canada.
Objectives This study evaluated the impact of clinical and physiological factors limiting treatment optimization toward recommended medical therapy in heart failure (HF).
Background Although guidelines aim to assist physicians in prescribing evidence-based therapies and to improve outcomes of patients with HF and reduced ejection fraction (HFrEF), gaps in clinical care persist.
Methods Medical records of all patients with HFrEF followed for at least 6 months at the authors’ HF clinic (n = 511) allowed for drug optimization and were reviewed regarding the prescription rates of recommended pharmacological agents and devices (implantable cardioverter-defibrillator [ICD] or cardiac resynchronization therapy [CRT]). Then, an algorithm integrating clinical (New York Heart Association [NYHA] functional class, heart rate, blood pressure and biologic parameters (creatinine, serum potassium) based on the inclusion/exclusion criteria of landmark trials guiding these recommendations) was applied for each agent and device to identify potential explanations for treatment gaps.
Results Gross prescription rates were high for beta-blockers (98.6%), mineralocorticoid receptor antagonist (MRA) (93.4%), vasodilators (90.3%), ICDs (75.1%), and CRT (82.1%) among those eligible, except for ivabradine (46.3%, n = 41). However, achievement of target physiological doses was lower (beta-blockers, 67.5%; MRA, 58.9%; and vasodilators, 63.4%), and one-fifth of patient dosages were still being up-titrated. Suboptimal doses were associated with older age (odds ratio [OR]: 1.221; p < 0.0001) and history of stroke or transient ischemic attack (TIA) (no vs. yes, OR: 0.264; p = 0.0336).
Conclusions Gaps in adherence to guidelines exist in specialized HF setting and are mostly explained by limiting physiological factors rather than inertia. Older age and history of stroke/TIA, potential markers of frailty, are associated with suboptimal doses of guideline-directed medical therapy, suggesting that an individualized rather than a “one-size-fits-all” approach may be required.
Dr. Ducharme holds the Fondation Marcelle et Jean Coutu, Cal and Janine Moisan chair in advanced heart failure. Dr. de Denus holds the Beaulieu-Saucier Chair in Pharmacogenomics. Dr. White holds the Carolyn and Richard Renaud Research Chair in Heart Failure of the Montreal Heart Institute. Supported by an unrestricted grant from Pfizer Canada. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Heart Failure author instructions page.
- Received November 19, 2019.
- Revision received April 13, 2020.
- Accepted April 30, 2020.
- 2020 American College of Cardiology Foundation
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