Heart failure patients who are treated in accordance with established European guidelines do better than patients who are not, yet many doctors are still not adhering to the guidelines, according to pioneering research published today (Tuesday 3 May) in Europe’s leading cardiology journal, the European Heart Journal.
In the first large European study to look at the effect of prescribing practices on outcome in heart failure outpatients outside of a clinical trial, Professor Michel Komajda and colleagues investigated the way that 1,410 patients with mild to moderate heart failure were treated by 150 randomly selected cardiologists or cardiology departments in six European countries (France, Germany, Italy, The Netherlands, Spain and the UK). They measured how closely the patients’ treatment adhered to the guidelines issued by the European Society of Cardiology (ESC) for the use of the five most commonly used cardiac drugs: ACE-inhibitors, beta-blockers, spironolactone, diuretics and cardiac glycosides.
Prof Komajda, professor of cardiology at the Pitie-Salpetriere Hospital, Paris, France, and a specialist in heart failure, said: "We found that where doctors had treated their patients in accordance with the ESC guidelines, fewer patients had to be referred to the hospital due to deterioration of their heart failure or for cardiovascular symptoms, and there was a longer time before patients had to be readmitted to hospital because of their symptoms.
"However, the study showed that only 60% of patients were treated according to the ESC guidelines with ACE-inhibitors, beta-blockers or spironolactone – the three cardiac drugs for which there is the strongest evidence of benefit – and only 63% of patients were treated according to the guidelines for these three drugs plus the two other commonly used drugs, cardiac glycosides and diuretics.
"This means there is a high proportion of patients who are not receiving the best possible treatment for their condition, and who suffer worsening symptoms and even death as a result."
Patients in the MAHLER study were aged 40 or over, with an average age of nearly 69. They were followed up for six months. The researchers found that while adherence to diagnosis guidelines was high at 74%, adherence to treatment guidelines was much lower, with large variations between the five different treatments; 85% of patients who needed them were prescribed ACE-inhibitors, 58% were given beta-blockers, 83% a diuretic agent, 52% a cardiac glycoside, and only 36% spironolactone.
When the researchers looked at the impact on outcome of the "big three" drugs (ACE-inhibitors, beta-blockers and spironolactone) they found that amongst patients who were treated with perfect adherence to the guidelines 6.7% and 11.2% were admitted to hospital with chronic heart failure (CHF) or a worsening of their cardiovascular (CV) symptoms respectively; this compared with figures of 9.7% and 15.9% respectively for moderate adherence and 14.7% and 20.6% for low adherence. These outcomes were independent of the severity of the disease, previous hospitalizations for CHF, or the presence of high blood pressure or diabetes.
"We found that adherence to treatment guidelines was independently and strongly correlated to outcome measured by rate of CHF or CV hospitalization and time to CV hospitalization," said Prof Komajda.
"We hope that these results will encourage cardiologists to ensure that they are familiar with, and adhere to, treatment guidelines. Integrated approaches, including nurses, dieticians, generalists and cardiologists, are needed in order to improve the management of chronic heart failure in clinical practice."
The researchers found there was plenty of room for improvement in the treatment of patients with heart failure. "Prescription of beta-blockers was observed in only half of the patients who should be receiving them, according to ESC guidelines. In contrast, a substantial proportion of our patients received cardiac glycosides despite the fact that this treatment is only recommended for symptomatic improvement. Overall, we found a high level of compliance to guidelines for ACE-inhibitors or diuretics, but a rather low level for beta-blockers, suggesting that there is still room for improving practice in Europe and that there is a need to develop training programmes to improve the quality of care for cardiac patients," said Prof Komajda.
A second paper published in the EHJ today underlines the difficulty of persuading doctors to follow guidelines for treatment rather than relying on their own impressions of what might be best. In some cases patients who most need the best treatment receive the worst, according to the authors.
Professor Jean-Pierre Bassand, head of the department of cardiology at the University Hospital Jean Minjoz, Besan’?on, France, said: "It is obvious that guidelines improve outcome, so it is hard to understand why they are adopted so poorly. Surveys have shown that a limited number of doctors actually know about the existence of the guidelines, and even when they do know, they do not necessarily put them into medical practice. Sometimes physicians feel they are flooded by too much information and a plethora of guidelines."
He said there might be several reasons why doctors do not follow guidelines: economic constraints, lack of belief in the guidelines and "nihilism". "This means that treatments with life-saving potential are under-prescribed for a wide variety of reasons, valid or otherwise," he said.
"In addition, it would even appear that in acute coronary syndromes, there is an inverse relation between the severity of the patient’s symptoms when they are first seen by a doctor and the level of compliance with the guidelines; in other words, the more severe the initial symptoms, the less likely the patient is to receive the most efficacious treatment."
Prof Bassand and his co-authors said that guidelines issued by professional organisations such as the ESC should be regarded as pivotal educational tools that are used in continuing medical education programmes, which all doctors should attend so that they can update and extend their knowledge.
"Doctors at the national level, health authorities and industry need to work together to make sure that these guidelines are implemented, with incentives towards medial practices that apply evidence-based medicine in their treatment schemes. Otherwise, many patients will continue to suffer unnecessarily," said Prof Bassand.
WordMason. April 2005.