Transcript Slide 1

Treatment and Risk in Heart Failure:
Gaps in Evidence or Quality?
Pamela N. Peterson, MD MSPH; John S. Rumsfeld, MD PhD; Li
Liang PhD; Adrian F. Hernandez, MD MHS; Eric D. Peterson,
MD MPH; Gregg C. Fonarow, MD; Frederick A Masoudi, MD
MSPH
Background
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ACE-Inhibitors or angiotensin receptor blockers (ARBs) and
beta blockers reduce morbidity and mortality in patients with
heart failure (HF) and left ventricular systolic dysfunction
(LVSD).
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The use of evidence-based therapies such as ACE-Inhibitors,
ARBs and beta blockers with HF and LVSD is significantly
lower in patients with increased risk.
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In order to optimize the use of evidence based therapies and
improve HF outcomes, more data is needed to assess how to
safely treat high risk patients with contraindications.
Peterson PN, et al. CIRCULATIONAHA/2009/879478
Introduction
Clinical practice guidelines recommend that certain evidencebased therapies are given to patients with HF and LVSD who do
not have a contraindication to that therapy. Research has
shown that high risk patients are less likely to receive these
evidence-based therapies.
Peterson, PN, et al. CIRCULATIONAHA/2009/879478
Objective
Using the data from the GWTG-HF database from GWTGHF participating hospitals, the purpose of the paper was to
evaluate whether high risk patients who do not receive
evidence based therapies is due to contraindications or
contributed to gaps in the quality of care.
Peterson, PN. et al. CIRCULATIONAHA/2009/879478
Methods
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Data were collected from 18,307 patients with left systolic dysfunction
surviving hospitalization between January 2005 and June 2007, from
194 GWTG-HF participating hospitals.
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The GWTG-HF risk prediction score was used to categorize patients
according to their estimated in-hospital mortality risk.
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The proportion of patients with documented contraindications and
without contraindications to ACE-inhibitors or ARBs and beta blockers
at hospital discharge was determined across all levels of risks. This
included worsening renal function and symptomatic hypotension,
median discharge serum creatinine and mean discharge blood
pressure.
Peterson, PN. et al. CIRCULATIONAHA/2009/879478
Results
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13% of the patient population had a documented contraindication
to ACE/ARBs and 7% to beta blockers.
Although the proportion of patients with documented
contraindications increased significantly with increasing risk, 67%
of patients in the highest risk group were still eligible for both
therapies.
The proportions of patients without a documented contraindication
received a discharge prescription for ACE-Inhibitors and ARBs was
84.9% and for beta blockers were 89.7%.
As mortality risk increased, the proportions of patients eligible for
therapy who were treated at discharge decreased for both
ACE/ARBs (p<0.001) and beta blockers (<0.001).
Peterson PN. et al. CIRCULATIONAHA/2009/879478
Peterson PN. et al. CIRCULATIONAHA/2009/879478
Peterson PN. et al. CIRCULATIONAHA/2009/879478
Peterson PN. et al. CIRCULATIONAHA/2009/879478
Peterson PN. et al. CIRCULATIONAHA/2009/879478
Conclusions
• The rates of use of guideline-based therapies in patients with
HF and LVSD were significantly lower as patient risk
increased due to high rates of contraindications to evidencebased therapies and low rates of use among eligible patients.
• The development of additional strategies is needed to assure
that eligible high-risk patients can safely receive evidencebased therapies.
• More broad evidence based strategies are warranted for while
those who are not eligible for guideline-based therapies.
Peterson, PN. et al. CIRCULATIONAHA/2009/879478