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Dose matters! Optimisation of guideline adherence is associated with lower mortality in stable patients with chronic
G Poelzl1, J Altenberger2, R Pacher3
1Clinical Division of Cardiology, Innsbruck Medical University, Austria.
Insights
Improving guideline adherence, especially medication dosing, in chronic heart failure (CHF) patients is linked to reduced mortality. This study highlights the importance of dose escalation for better outcomes in heart failure with reduced ejection fraction (HF-REF).
Area of Science:
- Cardiology
- Heart Failure Management
- Clinical Outcomes Research
Background:
- Established guidelines exist for managing chronic heart failure (CHF).
- The association between adherence to these guidelines and patient mortality requires further investigation.
- Focus on stable systolic heart failure with reduced ejection fraction (HF-REF) is crucial for targeted management.
Purpose of the Study:
- To examine the relationship between enhanced guideline adherence and the risk of all-cause death in patients with stable HF-REF.
- To assess the impact of improved guideline adherence indicator (GAI) and dose escalation (GAI50+) on mortality.
- To identify specific factors within guideline adherence that predict improved survival in CHF patients.
Main Methods:
- Analysis of ambulatory patients with HF-REF from the Austrian Heart Failure Registry (2006-2010).
- Calculation of Guideline Adherence Indicator (GAI) at baseline and 12 months, considering ACE-I/ARB, beta blockers, and MRA.
- Defined ΔGAI-positive (≥80% adherence) and ΔGAI50+ (≥50% target dose) for assessing improvement and dose escalation.
Main Results:
- Improvements in GAI and GAI50+ correlated with better NYHA class and reduced NT-proBNP levels (p<0.001).
- Improvements in GAI50+ (dose escalation) were independently predictive of lower mortality risk (HR 0.55; p=0.01), even after adjustments.
- General GAI improvement alone was not independently predictive of reduced mortality, emphasizing the role of dose.
Conclusions:
- Enhanced guideline adherence, particularly dose escalation of medications, is associated with decreased long-term mortality in ambulatory HF-REF patients.
- Achieving at least 50% of suggested target drug doses is a key factor in reducing mortality risk.
- These findings underscore the importance of optimizing drug dosage in guideline-directed medical therapy for heart failure.
Aims:
Guidelines have been published for improving management of chronic heart failure (CHF). We examined the association between improved guideline adherence and risk for all-cause death in patients with stable systolic HF.
Methods:
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 (≥ 80%). ΔGAI50+ positivity was ascribed to patients achieving a dose of ≥ 50% of suggested target dose.
Results:
Improvements in GAI and GAI50+ were associated with significant improvements in NYHA class and NT-proBNP (1728 [740-3636] to 970 [405-2348]) (p<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.
Conclusions:
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.
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