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Improving practice patterns in heart failure through a national cardiological network: the case of ACE-inhibitors
Maurizio Porcu1, Cristina Opasich, Marino Scherillo
1Heart Failure and Cardiac Transplant Unit, G. Brotzu Hospital, Cagliari, Italy. centro_studi@anmco.it
Insights
High rates of ACE-inhibitor treatment for chronic heart failure (CHF) were achieved through a national cardiology network and database. This initiative improved guideline compliance in routine clinical practice.
Area of Science:
- Cardiology
- Pharmacology
- Public Health
Background:
- Angiotensin-converting enzyme (ACE)-inhibitors offer significant survival benefits in chronic heart failure (CHF).
- Current prescription rates and dosages often fall below evidence-based survival-improving thresholds.
- The study investigated the impact of a specialist network and shared database on guideline adherence for ACE-inhibitor therapy in CHF.
Purpose of the Study:
- To assess the effectiveness of a national cardiology network and database in improving ACE-inhibitor prescription rates and dosages for chronic heart failure (CHF) patients.
- To identify factors influencing ACE-inhibitor prescription and dosage in a large CHF cohort.
Main Methods:
- Analysis of ACE-inhibitor utilization and dosage in 8102 CHF patients across 133 cardiology centers within a national network.
- Statistical evaluation of determinants for ACE-inhibitor non-prescription and suboptimal dosing.
Main Results:
- 82% of patients received ACE-inhibitors, with enalapril, captopril, and lisinopril being most common.
- Predictors of non-prescription included female gender, older age, valvular etiology, advanced NYHA class, and elevated creatinine.
- Factors increasing prescription rates were low ejection fraction and hypertensive or idiopathic etiology.
- 26.4% of patients received suboptimal ACE-inhibitor doses.
Conclusions:
- A national cardiology society's IN-CHF database initiative successfully promoted high ACE-inhibitor treatment rates in routine care.
- This educational and organizational approach demonstrates feasibility for improving guideline adherence in clinical practice.
- Further efforts may be needed to optimize prescribed ACE-inhibitor dosages.
Background:
Despite the well-established benefits of ACE-inhibitors in chronic heart failure (CHF), current treatment rates and prescribed doses are lower than those proven to improve survival. We evaluated whether participation in a specialist network and the use of a common database would impact on the compliance with CHF guidelines.
Methods:
We analyzed the rate and determinants of ACE-inhibitor use and prescribed doses among 8102 patients with CHF enrolled at 133 cardiology centers participating in a national network.
Results:
6625 patients (82%) took ACE-inhibitors, most commonly enalapril (41%, mean dose 16 +/- 9 mg), captopril (25%, mean dose 74 +/- 44 mg) and lisinopril (14%, mean dose 13 +/- 8 mg). The predictors of the non-prescription of ACE-inhibitors were: female gender (odds ratio--OR 1.46, 95% confidence interval-CI 1.28-1.67), older age (OR 1.01, 95% CI 1.01-1.02), valvular etiology (OR 1.87, 95% CI 1.60-2.20), NYHA class III-IV (OR 1.25, 95% CI 1.09-1.42) and creatinine levels > 2.5 mg/dl (OR 5.19, 95% CI 3.36-8.02). Conversely a left ventricular ejection fraction < 30% (OR 0.78, 95% CI 0.65-0.94) and a hypertensive (OR 0.69, 95% CI 0.55-0.86) or idiopathic (OR 0.67, 95% CI 0.57-0.78) etiology increased the rate of ACE-inhibitor prescription. Low ACE-inhibitor doses were prescribed to 26.4% of cases.
Conclusions:
The IN-CHF database, an educational and organizational effort led by a national cardiology society, demonstrates that high rates of ACE-inhibitor treatment may be achieved in routine clinical practice in a cardiology setting.