Skip to main content
SpringerLink
Log in

Guideline adherence for pharmacotherapy of chronic systolic heart failure in general practice: a closer look on evidence-based therapy

  • ORIGINAL PAPER
  • Published:
Clinical Research in Cardiology Aims and scope Submit manuscript

Abstract

Background

There is robust evidence for effective pharmacotherapy of chronic (systolic) heart failure (CHF) which has led to the creation of guidelines, but many surveys evaluating CHF treatment show an under-utilisation of relevant drugs, while setting and patient population appear to be crucial for adequate appraisal of treatment patterns.

Aims

To evaluate the guideline adherence (GA) of general practitioners (GPs) in a well-defined patient population with CHF in primary care (PC).

Methods

A cross-sectional analysis was performed with the data of 167 patients enrolled in 37 GP practices (Germany) with documented left ventricular systolic dysfunction (LVEF: 33.3 ± 6.9%). GA was assessed as usual (prescribing “yes” or “no”), through evaluation of target dosing, while adjusting for potential clinical contraindications, and through a modified Guideline Adherence Indicator-3 (mGAI-3), which assesses three relevant groups of substances according to New York Heart Association (NYHA) functional class: ACE-Inhibitors (ACE-I) or angiotensin receptor blockers (ARB), beta-blockers (BB) and aldosterone-antagonists (AA).

Results

Prescription rates for ACE-I/ARB, BB or both were 80%, 75% and 62%, respectively. The proportion of target doses reached for ACE-I was 16%, for BB only 8%. When adjusted for potential (mainly relative) contraindications (COPD, heart rate <60/min, hypotension, hyperkalaemia and renal dysfunction), the percentage of target doses reached increased to 49% for ACE-I/ARBs and 46% for BB. Application of the mGAI-3 showed moderate to perfect GA for usual assessment, proportion of target dose reached and adjusted in 83%, 16% and 55% of the patients, respectively.

Conclusion

In the context of this patient and doctor setting, life-saving treatment was provided above average when assessed by usual criteria. The application of additional criteria showed further room for improvement. Future interventions aiming at optimisation should be tailored to the needs of doctors and patients likewise.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. A fifth amendment for the declaration of Helsinki (2000) Lancet 356(9236): 1123

    Google Scholar 

  2. Bhatia RS, Tu JV, Lee DS, Austin PC, Fang J, Haouzi A, et al. (2006) Outcome of heart failure with preserved ejection fraction in a population-based study. N Engl J Med 355(3):260–269

    Article  PubMed  CAS  Google Scholar 

  3. Bongers FJ, Schellevis FG, Bakx C, van den Bosch WJ, van der Zee J (2006) Treatment of heart failure in Dutch general practice. BMC Fam Pract 7:40

    Article  PubMed  Google Scholar 

  4. Bouvy ML, Heerdink ER, Leufkens HG, Hoes AW (2003) Predicting mortality in patients with heart failure: a pragmatic approach. Heart 89(6):605–609

    Article  PubMed  CAS  Google Scholar 

  5. Cleland JG, Cohen-Solal A, Aguilar JC, Dietz R, Eastaugh J, Follath F, et al. (2002) Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet 360(9346): 1631–1639

    Article  PubMed  CAS  Google Scholar 

  6. Cleland JG, Swedberg K, Follath F, Komajda M, Cohen-Solal A, Aguilar JC, et al. (2003) The EuroHeart Failure survey programme—a survey on the quality of care among patients with heart failure in Europe. Part 1: patient characteristics and diagnosis. Eur Heart J 24(5):442–463

    Article  PubMed  CAS  Google Scholar 

  7. Drechsler K, Dietz R, Klein H, Wollert KC, Storp D, Molling J, et al. (2005) Euro heart failure survey. Medical treatment not in line with current guidelines. Z Kardiol 94(8):510–515

    Article  PubMed  CAS  Google Scholar 

  8. Freeman AC, Sweeney K (2001) Why general practitioners do not implement evidence: qualitative study. BMJ 323(7321):1100–1102

    Article  PubMed  CAS  Google Scholar 

  9. Friedrich EB, Teo KK, Bohm M (2006) ACE inhibition in secondary prevention: are the results controversial? Clin Res Cardiol 95(2):61–67

    Article  PubMed  CAS  Google Scholar 

  10. Hoppe UC, Bohm M, Dietz R, Hanrath P, Kroemer HK, Osterspey A, et al. (2005) Guidelines for therapy of chronic heart failure. Z Kardiol 94(8):488–509

    Article  PubMed  CAS  Google Scholar 

  11. Hoppe UC, Erdmann E (2001) Guidelines for the treatment of chronic heart failure. Issued by the Executive Committee of the German Society of Cardiology-Heart and Circulation Research, compiled on behalf of the Commission of Clinical Cardiology in cooperation with Pharmaceutic Commission of the German Physicians’ Association. Z Kardiol 90(3):218–237

    Article  PubMed  CAS  Google Scholar 

  12. Juenger J, Schellberg D, Kraemer S, Haunstetter A, Zugck C, Herzog W, et al. (2002) Health related quality of life in patients with congestive heart failure: comparison with other chronic diseases and relation to functional variables. Heart 87(3):235–241

    Article  PubMed  CAS  Google Scholar 

  13. Julian DG (2004) Translation of clinical trials into clinical practice. J Intern Med 255(3):309–316

    Article  PubMed  CAS  Google Scholar 

  14. Khunti K, Hearnshaw H, Baker R, Grimshaw G (2002) Heart failure in primary care: qualitative study of current management and perceived obstacles to evidence-based diagnosis and management by general practitioners. Eur J Heart Fail 4(6):771–777

    Article  PubMed  Google Scholar 

  15. Komajda M, Follath F, Swedberg K, Cleland J, Aguilar JC, Cohen-Solal A, et al. (2003) The EuroHeart Failure Survey programme—a survey on the quality of care among patients with heart failure in Europe. Part 2: treatment. Eur Heart J 24(5):464–474

    Article  PubMed  CAS  Google Scholar 

  16. Komajda M, Lapuerta P, Hermans N, Gonzalez-Juanatey JR, van Veldhuisen DJ, Erdmann E, et al. (2005) Adherence to guidelines is a predictor of outcome in chronic heart failure: the MAHLER survey. Eur Heart J 26(16):1653–1659

    Article  PubMed  Google Scholar 

  17. Lainscak M, Cleland JG, Lenzen MJ, Follath F, Komajda M, Swedberg K (2007) International variations in the treatment and co-morbidity of left ventricular systolic dysfunction: Data from the EuroHeart Failure Survey. Eur J Heart Fail 9(3):292–299

    Article  PubMed  Google Scholar 

  18. Lenzen MJ, Boersma E, Scholte op Reimer WJM, Balk AHMM, Komajda M, Swedberg K, et al. (2005) Under-utilization of evidence-based drug treatment in patients with heart failure is only partially explained by dissimilarity to patients enrolled in landmark trials: a report from the Euro Heart Survey on Heart Failure. Eur Heart J 26(24):2706–2713

    Article  PubMed  CAS  Google Scholar 

  19. Luke DR, Halstenson CE, Opsahl JA, Matzke GR (1990) Validity of creatinine clearance estimates in the assessment of renal function. Clin Pharmacol Ther 48(5):503–508

    Article  PubMed  CAS  Google Scholar 

  20. Muntwyler J, Cohen-Solal A, Freemantle N, Eastaugh J, Cleland JG, Follath F (2004) Relation of sex, age and concomitant diseases to drug prescription for heart failure in primary care in Europe. Eur J Heart Fail 6(5):663–668

    Article  PubMed  Google Scholar 

  21. O’Connell JB (2000) The economic burden of heart failure. Clin Cardiol 23(3 Suppl):6–10

    Google Scholar 

  22. Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM (2006) Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med 355(3):251–259

    Article  PubMed  CAS  Google Scholar 

  23. Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, et al. (1999) The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med 341(10):709–717

    Article  PubMed  CAS  Google Scholar 

  24. Reibis R, Dovifat C, Dissmann R, Ehrlich B, Schulz S, Stolze K, et al. (2006) Implementation of evidence-based therapy in patients with systolic heart failure from 1998–2000. Clin Res Cardiol 95(3):154–161

    Article  PubMed  CAS  Google Scholar 

  25. Remme WJ, Swedberg K (2002) Comprehensive guidelines for the diagnosis and treatment of chronic heart failure. Task force for the diagnosis and treatment of chronic heart failure of the European Society of Cardiology. Eur J Heart Fail 4(1):11–22

    Article  PubMed  Google Scholar 

  26. Rickham PP (1964) Human experimentation. Code of ethics of the world medical association. Declaration of helsinki. Br Med J 2(5402):177

    Article  PubMed  CAS  Google Scholar 

  27. Rutten FH, Grobbee DE, Hoes AW (2003) Differences between general practitioners and cardiologists in diagnosis and management of heart failure: a survey in every-day practice. Eur J Heart Fail 5(3):337–344

    Article  PubMed  Google Scholar 

  28. Shekelle PG, Rich MW, Morton SC, Atkinson CS, Tu W, Maglione M, et al. (2003) Efficacy of angiotensin-converting enzyme inhibitors and beta-blockers in the management of left ventricular systolic dysfunction according to race, gender, and diabetic status: a meta-analysis of major clinical trials. J Am Coll Cardiol 41(9):1529–1538

    Article  PubMed  CAS  Google Scholar 

  29. Simpson SH, Eurich DT, Majumdar SR, Padwal RS, Tsuyuki RT, Varney J, et al. (2006) A meta-analysis of the association between adherence to drug therapy and mortality. BMJ 333(7557):15

    Article  PubMed  Google Scholar 

  30. Stewart S, MacIntyre K, Hole DJ, Capewell S, McMurray JJ (2001) More ‘malignant’ than cancer? Five-year survival following a first admission for heart failure. Eur J Heart Fail 3(3):315–322

    Article  PubMed  CAS  Google Scholar 

  31. Swedberg K, Cleland J, Dargie H, Drexler H, Follath F, Komajda M, et al. (2005) Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005). The task force for the diagnosis and treatment of chronic heart failure of the European Society of Cardiology. Eur Heart J 26(11):1115–1140

    Article  PubMed  Google Scholar 

  32. The Heart Outcomes Prevention Evaluation Study Investigators (2000) Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 342(3):145–153

    Article  Google Scholar 

  33. Wikstrand J, Hjalmarson A, Waagstein F, Fagerberg B, Goldstein S, Kjekshus J, et al. (2002) Dose of metoprolol CR/XL and clinical outcomes in patients with heart failure: analysis of the experience in metoprolol CR/XL randomized intervention trial in chronic heart failure (MERIT-HF). J Am Coll Cardiol 40(3):491–498

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgements

We are indebted to the participating GPs and staff members for providing data. This work was supported by the Competence Network of Heart Failure, funded by the German Federal Ministry of Education and Research (BMBF), FKZ 01GI0205. We are grateful to the staff members of the Coordination Centre for Clinical Trials (KKS) at the University of Leipzig responsible for our study. The study was supported by the Competence Network of Heart Failure, funded by the German Ministry of Education and Research (BMBF).

Author information

Authors and Affiliations

  1. Department of General Practice and Health Services Research, University Hospital Heidelberg, Voßstraße 2, Heidelberg, 69115, Germany

    F. Peters-Klimm MD, A. Barth & J. Szecsenyi MD, MSc

  2. Department of Psychosomatic and General Internal Medicine, University Hospital Heidelberg, Heidelberg, 69120, Germany

    T. Müller-Tasch MD, D. Schellberg PhD, N. Holzapfel MA, J. Jünger MD & W. Herzog MD

  3. Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg, 69120, Germany

    A. Remppis MD

Authors
  1. F. Peters-Klimm MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. T. Müller-Tasch MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. D. Schellberg PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. A. Remppis MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. A. Barth
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. N. Holzapfel MA
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. J. Jünger MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. W. Herzog MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. J. Szecsenyi MD, MSc
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to F. Peters-Klimm MD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Peters-Klimm, F., Müller-Tasch, T., Schellberg, D. et al. Guideline adherence for pharmacotherapy of chronic systolic heart failure in general practice: a closer look on evidence-based therapy. Clin Res Cardiol 97, 244–252 (2008). https://doi.org/10.1007/s00392-007-0617-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00392-007-0617-6

Key words

Search

Navigation