CAN CARE GAPS IN ADHERENCE TO GUIDELINES THERAPY IN AN OUTPATIENT SPECIALIZED HEART FAILURE SETTING BE EXPLAINED BY CLINICAL AND PHYSIOLOGICAL FACTORS RATHER THAN CLINICAL INERTIA
CCC ePoster Library. Jarjour M. 10/26/19; 280520; 285
Marilyne Jarjour
Marilyne Jarjour
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Abstract
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BACKGROUND: Although national guidelines aim to assist physicians in prescribing evidence-based therapies and improve outcomes of patients with heart failure and reduced ejection fraction (HFrEF), gaps in clinical care persist. While clinical inertia has been proposed to explain those gaps, we hypothesized that physiological factors may be at least partially responsible for less than optimal adherence to guidelines-derived medical therapies (GDMT).

METHODS AND RESULTS: We reviewed the electronic medical records of patients with HFrEF followed at the Montreal Heart Institute's HF clinic for at least 6 months, period allowed for medications' optimization. First, prescription rates of beta-blockers, vasodilators [angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI)], mineralocorticoid receptor antagonists (MRA) and ivabradine were evaluated. Then, an algorithm integrating clinical (NYHA class, heart rate, blood pressure) and biological parameters (creatinine, potassium) based on inclusion/exclusion criteria of landmark trials guiding these recommendations was applied for each pharmacological class to identify potential explanations for treatment gaps. Overall, 511 HFrEF patients were included (74.8% males; mean age: 68.5±13.4 years). Prescription rates of beta-blockers, MRA, ARNI and ACEI/ARB were high (TABLE). By contrast, only 45.9% of those eligible for ivabradine (once beta-blockers optimized, n=37, only 7.3% of the cohort remained eligible) were receiving this agent. However, achievement of target/physiological or maximally tolerated doses obtained using the algorithm was lower for all pharmacological class: beta-blockers (70.4%), ACEI/ARB/ARNI (68.5%) and MRA (60.1%), while approximately one quarter of patients were still being up-titrated. Therefore, only a very small percentage of patients were truly undertreated. Sub-optimal up-titration of triple therapy was associated with older age (OR:1.228; 95% CI: 1.132-1.333, p < 0.0001) and advanced NYHA class (OR:1.893; 95% CI: 1.009-3.550, p < 0.05), while gender and comorbidities (COPD, atrial fibrillation) had no impact.

CONCLUSION: Gaps in adherence to target dose of GDMT exist in specialized HF ambulatory care and can be mostly explained by physiological and biological parameters rather than clinical inertia. Older age and advanced symptoms are associated with achievement of less than targeted up-titration of GDMT, suggesting that patients' individual factors and frailty play an important role in pharmacological optimization and that individualized treatment rather than the recommenced ''one-size-fits-all'' approach is required.
BACKGROUND: Although national guidelines aim to assist physicians in prescribing evidence-based therapies and improve outcomes of patients with heart failure and reduced ejection fraction (HFrEF), gaps in clinical care persist. While clinical inertia has been proposed to explain those gaps, we hypothesized that physiological factors may be at least partially responsible for less than optimal adherence to guidelines-derived medical therapies (GDMT).

METHODS AND RESULTS: We reviewed the electronic medical records of patients with HFrEF followed at the Montreal Heart Institute's HF clinic for at least 6 months, period allowed for medications' optimization. First, prescription rates of beta-blockers, vasodilators [angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI)], mineralocorticoid receptor antagonists (MRA) and ivabradine were evaluated. Then, an algorithm integrating clinical (NYHA class, heart rate, blood pressure) and biological parameters (creatinine, potassium) based on inclusion/exclusion criteria of landmark trials guiding these recommendations was applied for each pharmacological class to identify potential explanations for treatment gaps. Overall, 511 HFrEF patients were included (74.8% males; mean age: 68.5±13.4 years). Prescription rates of beta-blockers, MRA, ARNI and ACEI/ARB were high (TABLE). By contrast, only 45.9% of those eligible for ivabradine (once beta-blockers optimized, n=37, only 7.3% of the cohort remained eligible) were receiving this agent. However, achievement of target/physiological or maximally tolerated doses obtained using the algorithm was lower for all pharmacological class: beta-blockers (70.4%), ACEI/ARB/ARNI (68.5%) and MRA (60.1%), while approximately one quarter of patients were still being up-titrated. Therefore, only a very small percentage of patients were truly undertreated. Sub-optimal up-titration of triple therapy was associated with older age (OR:1.228; 95% CI: 1.132-1.333, p < 0.0001) and advanced NYHA class (OR:1.893; 95% CI: 1.009-3.550, p < 0.05), while gender and comorbidities (COPD, atrial fibrillation) had no impact.

CONCLUSION: Gaps in adherence to target dose of GDMT exist in specialized HF ambulatory care and can be mostly explained by physiological and biological parameters rather than clinical inertia. Older age and advanced symptoms are associated with achievement of less than targeted up-titration of GDMT, suggesting that patients' individual factors and frailty play an important role in pharmacological optimization and that individualized treatment rather than the recommenced ''one-size-fits-all'' approach is required.
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