Tuesday, September 16, 2014

Guideline adherence and outcomes in heart failure

Here's an interesting study from the International Journal of Cardiology:

Data on ambulatory patients (2006–2010) with CHF and reduced ejection fraction (HF-REF) from the Austrian Heart Failure Registry (HIR Austria) were analysed. One-year clinical data and long-term follow-up data until all-cause death or data censoring were available for 1014 patients (age 65 [55–73], male 75%, NYHA class I 14%, NYHA II 56%, NYHA III/IV 30%). A guideline adherence indicator (GAI [0–100%]) was calculated for each patient at baseline and after 12 ± 3 months that considered indications and contraindications for ACE-I/ARB, beta blockers, and MRA. Patients were considered ΔGAI-positive if GAI improved to or remained at high levels (greater than of equal to 80%). ΔGAI50+ positivity was ascribed to patients achieving a dose of greater than or equal to 50% of suggested target dose.

Improvements in GAI and GAI50+ were associated with significant improvements in NYHA class and NT-proBNP (1728 [740–3636] to 970 [405–2348]) (p less than 0.001). Improvements in GAI50+, but not GAI, were independently predictive of lower mortality risk (HR 0.55 [95% CI 0.34–0.87; p = 0.01]) after adjustment for a large variety of baseline parameters and hospitalisation for heart failure during follow-up.

Improvement in guideline adherence with particular emphasis on dose escalation is associated with a decrease in long-term mortality in ambulatory HF-REF subjects surviving one year after registration.

This is one explanation of why heart failure performance measures are not valid. They do not address titration of medications to goal.

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