Guideline-led prescribing to ambulatory heart failure patients in a cardiology outpatient service

Background Guidelines recommend heart failure (HF) patients be treated with multiple medications at doses proven to improve clinical outcomes. Objective To study guideline-led prescribing in an Irish outpatient HF population. Setting Cardiology Outpatient Clinic, Mercy University Hospital, Cork, Ireland. Methods Guideline-led prescribing was assessed using the Guideline Adherence Index (GAI-3), that considered the prescribing of ACE inhibitors and angiotensin receptor blockers; beta-blockers and mineralocorticoid receptor antagonists. The GAI-based target dose was calculated based on the prescription of ≥ 50% of the guideline-recommended target dose of each of the three GAI medications to HF patients with ejection fraction ≤ 40%. High-GAI was achieved by prescription of ≥ 2 GAI medicines. Potentially inappropriate prescribing was assessed using a HF-specific tool. Main outcome measure Heart failure guideline-led prescribing assessed using the GAI-3. Results A total of 127 HF patients, mean age 71.7 ± 13.1 years, were identified in the study. Seventy-one patients had ejection fraction ≤ 40%. Population mean GAI-3 was 65.8%. When contraindications to therapy are considered, the adjusted GAI-3 increased to 72.9%. The target dose GAI was 18.5%. High-GAI management was prescribed to 54 patients (76.1%). A potentially inappropriate medicine in HF was prescribed to 14 (19.7%) patients. Conclusion Most HF patients with ejection fraction ≤ 40% in this setting received optimal guideline-led prescribing however the proportion of patients achieving the target doses of these agents was suboptimal.

Adherence to ESC guideline-recommended medications over a 36-month follow-up period after hospitalization for heart failure: Results from the EPICAL2 cohort study

PURPOSE

The purpose of the study is to describe the trajectories of oral medication prescriptions in patients with heart failure with reduced ejection fraction (HFrEF) over 3 years after discharge from hospitalization for heart failure. We then evaluated the adherence of these prescriptions to the European Society of Cardiology (ESC) guideline-recommended medications and identified patient characteristics associated with nonadherence.

METHODS

We used data from the EPICAL2 cohort study. HFrEF patients who had completed prescriptions at discharge and at 6-month follow-up were included and followed for 36 months. The following medication agents were considered adherent to guidelines: renin-angiotensin system (RAS) blockers [angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin-receptor blocker (ARB)] plus a β-blocker (BB) or RAS blocker plus BB plus mineralocorticoid receptor antagonists (MRAs). The evolution of drug prescriptions and the adherence to ESC guidelines were assessed by using sequence analysis and clustering approaches. Patient characteristics associated with nonadherence were identified by logistic regression analyses.

RESULTS

A typology of four therapeutic clusters was obtained, among which two clusters were adherent to recommendations and two were not. The adherent clusters consisted of bitherapy (RAS blockers-BB) and tritherapy (RAS blockers-BB-MRA) for about 64% of patients and remain stable over time. The nonadherent clusters consisted of nonprescription of BB for about 22% of patients or nonprescription of RAS blocker for about 14%. The main reason for nonprescription of BB was a concomitant obstructive airway disease (asthma or COPD) but was a concomitant chronic kidney disease for nonprescription of RAS blocker.

CONCLUSION

Adherence to guideline-recommended medications while being hospitalized is of great importance because prescriptions are quite stable over time after discharge. HFrEF patients are most often older, with various comorbidities, such as chronic kidney disease or asthma/COPD, which importantly limit physicians' ability to prescribe recommended drugs, leading to suboptimal adherence to guidelines.

Medical therapy doses at hospital discharge in patients with existing and de novo heart failure

AIMS

Uptitrating angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACE-I/ARBs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs) to optimal doses in heart failure with reduced ejection fraction (HFrEF) is associated with improved outcomes and recommended in guidelines. Studies of ambulatory patients found that a minority are prescribed optimal doses. However, dose at hospital discharge has rarely been reported. This information may guide quality improvement initiatives during and following discharge.

METHODS AND RESULTS

We assessed 370 consecutive patients with HFrEF hospitalized at two centres in Vancouver, Canada. Of those without contraindications, 86.4%, 93.4%, and 44.7% were prescribed an ACE-I/ARB/sacubitril-valsartan, beta-blocker, or MRA, respectively. The proportion of eligible patients prescribed target dose was respectively 28.6%, 31.7%, and 4.1%. Forty-two of 248 eligible patients (16.9%) were prescribed ≥50% of target dose, and only three patients received target dosing of all three medication classes. In multivariate regression models, cardiologist involvement in care was independently associated with increased dose and prescription of ≥50% of target dose for all medications, whereas a history of HF was only predictive for beta-blockers.

CONCLUSIONS

In a single-region experience of hospitalized HFrEF patients, a high proportion of eligible patients were discharged on ACE-I/ARB or beta-blocker. Less than half were prescribed MRAs, and few were prescribed ≥50% or target dosing of all medications. Further exploration into barriers to medication uptitration, and improvement in processes of care, is needed.

A tool for assessment of heart failure prescribing quality: A systematic review and meta-analysis

INTRODUCTION

Heart failure (HF) guidelines aim to standardise patient care. Internationally, prescribing practice in HF may deviate from guidelines and so a standardised tool is required to assess prescribing quality. A systematic review and meta-analysis were performed to identify a quantitative tool for measuring adherence to HF guidelines and its clinical implications.

METHODS

Eleven electronic databases were searched to include studies reporting a comprehensive tool for measuring adherence to prescribing guidelines in HF patients aged ≥18 years. Qualitative studies or studies measuring prescription rates alone were excluded. Study quality was assessed using the Good ReseArch for Comparative Effectiveness Checklist.

RESULTS

In total, 2455 studies were identified. Sixteen eligible full-text articles were included (n = 14 354 patients, mean age 69 ± 8 y). The Guideline Adherence Index (GAI), and its modified versions, was the most frequently cited tool (n = 13). Other tools identified were the Individualised Reconciled Evidence Recommendations, the Composite Heart Failure Performance, and the Heart Failure Scale. The meta-analysis included the GAI studies of good to high quality. The average GAI-3 was 62%. Compared to low GAI, high GAI patients had lower mortality rate (7.6% vs 33.9%) and lower rehospitalisation rates (23.5% vs 24.5%); both P ≤ .05. High GAI was associated with reduced risk of mortality (hazard ratio = 0.29, 95% confidence interval, 0.06-0.51) and rehospitalisation (hazard ratio = 0.64, 95% confidence interval, 0.41-1.00). No tool was used to improve prescribing quality.

CONCLUSION

The GAI is the most frequently used tool to assess guideline adherence in HF. High GAI is associated with improved HF outcomes.

The treatment gap in patients with chronic systolic heart failure: a systematic review of evidence-based prescribing in practice

The extent and impact of under-prescribing of evidence-based pharmacological therapies among heart failure patients with reduced ejection fraction (HFREF) in contemporary practice is unclear. We sought to examine the prescribing patterns of angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), β-blockers (BBs) and mineralocorticoid receptor antagonists (MRAs), and to quantify the estimated 'treatment gap' among HFREF patients in the 'real-world' setting. The MEDLINE, PubMed, EMBASE, CINAHL and CENTRAL databases were searched for registry- or survey-based studies which examined the prescribing rates of ACE inhibitors, ARBs, BBs and MRAs among HFREF patients. Searches were limited to those published in the years 2000-2015. A total of 23 reports, including 83,605 patients, were evaluated. Overall, ACE inhibitors/ARBs, BBs and MRAs were prescribed to 79.8, 81.4 and 36.4 % of patients, respectively. The estimated treatment gaps in the overall population were 13.1 % for ACE inhibitors/ARBs, 3.9 % for BBs and 16.8 % for MRAs. The proportion of patients who received ≥50 % of the guideline-recommended target doses was 72 % for ACE inhibitors, 51 % for ARBs, 49 % for BBs, 53 % for the combination of ACE inhibitors/ARBs and BBs and 83 % for MRAs. Prescribing these drugs according to contemporary guidelines was associated with lower mortality risk. Patients who were elderly, female and with comorbidities were less likely to receive optimal treatment as recommended by the guidelines. ACE inhibitors, ARBs, BBs and MRAs are under-prescribed in eligible HFREF patients. Efforts should be made to improve approaches to closing the treatment gap at both systems of care and individual levels.

Heart failure in patients with coronary heart disease: Prevalence, characteristics and guideline implementation - Results from the German EuroAspire IV cohort

Background

Adherence to pharmacotherapeutic treatment guidelines in patients with heart failure (HF) is of major prognostic importance, but thorough implementation of guidelines in routine care remains insufficient. Our aim was to investigate prevalence and characteristics of HF in patients with coronary heart disease (CHD), and to assess the adherence to current HF guidelines in patients with HF stage C, thus identifying potential targets for the optimization of guideline implementation.

Methods

Patients from the German sample of the European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EuroAspire) IV survey with a hospitalization for CHD within the previous six to 36 months providing valid data on echocardiography as well as on signs and symptoms of HF were categorized into stages of HF: A, prevalence of risk factors for developing HF; B, asymptomatic but with structural heart disease; C, symptomatic HF. A Guideline Adherence Indicator (GAI-3) was calculated for patients with reduced (≤40%) left ventricular ejection fraction (HFrEF) as number of drugs taken per number of drugs indicated; beta-blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, and mineralocorticoid receptor antagonists (MRA) were considered.

Results

509/536 patients entered analysis. HF stage A was prevalent in n = 20 (3.9%), stage B in n = 264 (51.9%), and stage C in n = 225 (44.2%) patients; 94/225 patients were diagnosed with HFrEF (42%). Stage C patients were older, had a longer duration of CHD, and a higher prevalence of arterial hypertension. Awareness of pre-diagnosed HF was low (19%). Overall GAI-3 of HFrEF patients was 96.4% with a trend towards lower GAI-3 in patients with lower LVEF due to less thorough MRA prescription.

Conclusions

In our sample of CHD patients, prevalence of HF stage C was high and a sizable subgroup suffered from HFrEF. Overall, pharmacotherapy was fairly well implemented in HFrEF patients, although somewhat worse in patients with more reduced ejection fraction. Two major targets were identified possibly suited to further improve the implementation of HF guidelines: 1) increase patients´ awareness of diagnosis and importance of HF; and 2) disseminate knowledge about the importance of appropriately implementing the use of mineralocorticoid receptor antagonists.

Trial registration

This is a cross-sectional analysis of a non-interventional study. Therefore, it was not registered as an interventional trial.

Understanding the Epidemiology of Heart Failure to Improve Management Practices: An Asia-Pacific Perspective

Heart failure (HF) is a major global healthcare problem with an estimated prevalence of approximately 26 million. In Asia-Pacific regions, HF is associated with a significant socioeconomic burden and high rates of hospital admission. Epidemiological data that could help to improve management approaches to address this burden in Asia-Pacific regions are limited, but suggest patients with HF in the Asia-Pacific are younger and have more severe signs and symptoms of HF than those of Western countries. However, local guidelines are based largely on the European Society of Cardiology and American College of Cardiology Foundation/American Heart Association guidelines, which draw their evidence from studies where Western patients form the major demographic and patients from the Asia-Pacific region are underrepresented. Furthermore, regional differences in treatment practices likely affect patient outcomes. In the following review, we examine epidemiological data from existing regional registries, which indicate that these patients represent a distinct subpopulation of patients with HF. In addition, we highlight that patients with HF are under-treated in the region despite the existence of local guidelines. Finally, we provide suggestions on how data can be enriched throughout the region, which may positively affect local guidelines and improve management practices.

Age- and sex-related differences in use of guideline-recommended care and mortality among patients with incident heart failure in Denmark

BACKGROUND

data are sparse on age- and sex-related differences in use of guideline-recommended care and subsequent mortality among patients with heart failure (HF).

METHODS

we identified 24,308 incident patients with a verified primary diagnosis of HF recorded during 2003-2010 in the Danish Heart Failure Registry. The registry monitors guideline-recommended processes of care: echocardiography, New York Heart Association Classification, treatment with angiotensin converting enzyme inhibitors/angiotensin II receptor blockers, betablockers, physical training and patient education.

RESULTS

older age was associated with lower use of recommended processes of care. Relative risk (RR) for receiving processes of care varied for men >80 years from 0.52 to 0.91 compared with men ≤65 years. Corresponding RRs among women >80 years varied from 0.55 to 0.89 compared with women ≤65 years. Older age was as expected associated with higher 1 year mortality (32.6% among men >80 years versus 5.4% among men ≤65 years and 33.8% among women >80 years versus 6.6% among women ≤65 years). The corresponding hazard ratios (HRs) were 4.54 (95% CI 3.93-5.25) and 4.08 (95% CI 3.51-4.75) for the oldest versus youngest men and women, after adjustment for patient characteristics. Adjustment for differences in care lowered HRs among the oldest age groups (adjusted HR 3.87 for men and 3.48 for women, respectively). The findings were also confirmed when stratifying the patients according to left ventricular ejection fraction ≤40% and >40%.

CONCLUSION

older patients with HF were less likely to receive guideline-recommended processes of care, irrespective of sex. Lower level of care may contribute to an excess mortality observed among the older patients.

[Differences between German and Turkish-speaking participants in a chronic heart failure management program]

BACKGROUND

German and Turkish-speaking patients were recruited for a chronic heart failure management program. So far little is known about the special needs and characteristics of Turkish-speaking patients with chronic heart failure; therefore, the aim of this study was to examine sociodemographic and illness-related differences between German and Turkish-speaking patients with chronic heart failure.

METHODS

German and Turkish-speaking patients suffering from chronic heart failure and insured with the AOK Rheinland/Hamburg or the BARMER GEK health insurance companies and living in Cologne, Germany, were enrolled. Recruitment took place in hospitals, private practices and at information events. Components of the program were coordination of a guideline-oriented medical care, telemonitoring (e.g., blood pressure, electrocardiogram, and weight), a 24-h information hotline, attendance by German and Turkish-speaking nurses and a patient education program. Data were collected by standardized interviews in German or Turkish language. Data were analyzed with descriptive measures and tested for significance differences using Pearson's χ²-test and the t‑test.

RESULTS

A total of 465 patients (average age 71 years, 55 % male and 33 % Turkish-speaking) were enrolled in the care program during the study period. Significant differences between German and Turkish-speaking patients were found for age, education, employment status, comorbidities, risk perception, knowledge on heart failure and fear of loss of independence.

DISCUSSION

The response rate could be achieved with the help of specific measures for patient enrollment by Turkish-speaking integration nurses. The differences between German and Turkish-speaking patients should in future be taken into account in the care of people with chronic heart failure.

Therapy modifications during hospitalization in patients with chronic heart failure

BACKGROUND

Guidelines on suggested pharmacological treatments for heart failure (HF) are not optimally implemented in clinical practice and whether pharmacotherapy adjustment actually happens in daily practice is largely unknown. We aimed to investigate pharmacotherapy modifications during hospitalization.

METHODS

This was a prospective observational survey where all admissions were screened for HF; 210 patients were included. The guideline adherence index (GAI) and modified GAI (mGAI, if ≥50% of target dose) were used to grade the pharmacotherapy.

RESULTS

Among 198 patients discharged alive (mean age 77years, 51% male), 49% had preserved left ventricular ejection fraction (PLVEF) and 30% had left ventricular systolic dysfunction (LVSD); the echocardiography report was unavailable for 21%. Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists were prescribed to 78%, 58% and 20% of patients on admission and 72%, 65% and 23% at discharge, respectively. Overall, 14% of patients met GAI-3, but at discharge only 7% met mGAI-3. One of the key drugs was stopped or down-titrated in 27%. During follow-up, 21% of patients died (25% with LVSD). Patients with LVSD discharged with at least one HF drug had a lower risk of death than patients with none (HR=0.142, 95% CI=0.029-0.683, p=0.015). Patients with PLVEF had better prognosis than LVSD patients when no HF drugs were prescribed at discharge (HR=0.075, 95% CI=0.009-0.627, p=0.017).

CONCLUSIONS

The pharmacotherapy of HF patients did not improve significantly during hospitalization, remaining suboptimal. Treatment with key drugs was terminated or reduced in a significant proportion of patients, mostly without specific written justification.

Improving care for patients with acute heart failure: before, during and after hospitalization

Acute heart failure (AHF) is a common and serious condition that contributes to about 5% of all emergency hospital admissions in Europe and the USA. Here, we present the recommendations from structured discussions among an author group of AHF experts in 2013. The epidemiology of AHF and current practices in diagnosis, treatment, and long-term care for patients with AHF in Europe and the USA are examined. Available evidence indicates variation in the quality of care across hospitals and regions. Challenges include the need for rapid diagnosis and treatment, the heterogeneity of precipitating factors, and the typical repeated episodes of decompensation requiring admission to hospital for stabilization. In hospital, care should involve input from an expert in AHF and auditing to ensure that guidelines and protocols for treatment are implemented for all patients. A smooth transition to follow-up care is vital. Patient education programmes could have a dramatic effect on improving outcomes. Information technology should allow, where appropriate, patient telemonitoring and sharing of medical records. Where needed, access to end-of-life care and support for all patients, families, and caregivers should form part of a high-quality service. Eight evidence-based consensus policy recommendations are identified by the author group: optimize patient care transitions, improve patient education and support, provide equity of care for all patients, appoint experts to lead AHF care across disciplines, stimulate research into new therapies, develop and implement better measures of care quality, improve end-of-life care, and promote heart failure prevention.

Meta-regression analyses to explain statistical heterogeneity in a systematic review of strategies for guideline implementation in primary health care

This study is an in-depth-analysis to explain statistical heterogeneity in a systematic review of implementation strategies to improve guideline adherence of primary care physicians in the treatment of patients with cardiovascular diseases. The systematic review included randomized controlled trials from a systematic search in MEDLINE, EMBASE, CENTRAL, conference proceedings and registers of ongoing studies. Implementation strategies were shown to be effective with substantial heterogeneity of treatment effects across all investigated strategies. Primary aim of this study was to explain different effects of eligible trials and to identify methodological and clinical effect modifiers. Random effects meta-regression models were used to simultaneously assess the influence of multimodal implementation strategies and effect modifiers on physician adherence. Effect modifiers included the staff responsible for implementation, level of prevention and definition pf the primary outcome, unit of randomization, duration of follow-up and risk of bias. Six clinical and methodological factors were investigated as potential effect modifiers of the efficacy of different implementation strategies on guideline adherence in primary care practices on the basis of information from 75 eligible trials. Five effect modifiers were able to explain a substantial amount of statistical heterogeneity. Physician adherence was improved by 62% (95% confidence interval (95% CI) 29 to 104%) or 29% (95% CI 5 to 60%) in trials where other non-medical professionals or nurses were included in the implementation process. Improvement of physician adherence was more successful in primary and secondary prevention of cardiovascular diseases by around 30% (30%; 95% CI -2 to 71% and 31%; 95% CI 9 to 57%, respectively) compared to tertiary prevention. This study aimed to identify effect modifiers of implementation strategies on physician adherence. Especially the cooperation of different health professionals in primary care practices might increase efficacy and guideline implementation seems to be more difficult in tertiary prevention of cardiovascular diseases.

Dose matters! Optimisation of guideline adherence is associated with lower mortality in stable patients with chronic 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.

Clinical characteristics, morbidity, and prognostic value of concomitant coronary artery disease in idiopathic dilated cardiomyopathy

BACKGROUND

Patients with idiopathic dilated cardiomyopathy (dCMP) might present coronary artery disease (CAD) concomitant to dCMP and prognostic differences between ischemic heart disease and non-ischemic cardiomyopathy have been described. Clinical characteristics and prognostic implications of concomitant CAD in patients with dCMP are largely unknown.

METHODS

A total of 1,263 patients with chronic systolic dysfunction from dCMP-of these 67.1 % (n = 847; 72.3 % men) without and 32.9 % (n = 416; 80.8 % men) with concomitant CAD were included and baseline clinical characteristics noted. They were followed prospectively for 36.3 (20.8-65.0) months, representing 5,168 patient-years. All-cause mortality was the primary endpoint; and decompensation requiring hospitalisation as well as the combined endpoint thereof were secondary endpoints.

RESULTS

Independent significant predictors of CAD were smoking status (current smoker: OR 2.68, 95 % CI 1.61-4.46; p < 0.001; past smoker: OR 2.52, 95 % CI 1.40-4.52; p < 0.005; each vs. non-smoker), presence of dyslipidemia (OR 3.46, 95 % CI 2.23-5.35; p < 0.001), age (OR 1.06, 95 % CI 1.04-1.08; p < 0.001), and female sex (OR 0.49, 95 % CI 0.29-0.81; p = 0.005). The presence of CAD was not a significant predictor of all-cause mortality (adjusted HR 0.74, 95 % CI 0.36-1.54; p = 0.42), morbidity (adjusted HR 1.48, 95 % CI 0.55-3.99; p = 0.44), or the combined endpoint (HR 0.65, 95 % CI 0.24-1.78; p = 0.40).

CONCLUSION

Concomitant CAD is common in patients with dCMP. Clinical predictors of its presence are largely coincident with classic risk factors in the general population. The presence of concomitant CAD appears not to be associated with adverse prognosis (morbidity or mortality) in patients with dCMP.

Heart rate achieved or beta-blocker dose in patients with chronic heart failure: which is the better target?

AIMS

To investigate whether the mortality of patients with chronic heart failure (CHF) due to left ventricular systolic dysfunction (LVSD) is more strongly related to beta-blocker dose or to heart rate. It is known that beta-blockers reduce mortality in patients with CHF and LVSD, but the primary mechanism of action is uncertain.

METHODS AND RESULTS

Patients with an ejection fraction ≤40%, who were in sinus rhythm both at an initial (visit 1) and at a 4-month clinic review (visit 2), were followed for a maximum of 36 months. The relationships between heart rate, beta-blocker dose, and survival in a multivariable model were examined. Of 654 eligible patients, 381 (58%) were started on beta-blockers prior to the initial visit, increasing to 537 (82%) by visit 2. During follow-up, 142 (22%) patients died. Neither resting heart rate nor beta-blocker dose at visit 1 predicted mortality (P = 0.09 and P = 0.99), but resting heart rate at visit 2 did (P = 0.02). Beta-blocker use at visit 2 was associated with better outcome (P = 0.03) but with little variation in outcome according to dose. Patients with a heart rate of 58-64 b.p.m. at visit 2 had the best prognosis.

CONCLUSIONS

The use of beta-blockers and resting heart rate at visit 2 both independently indicated prognosis, but beta-blocker dose did not. Beta-blockers may reduce mortality by several mechanisms; one that may be specific to blockade of adrenergic receptors and another related to heart rate reduction. Achieving a target heart rate range may be an appropriate therapeutic goal for patients with CHF.

Telemedicine in heart failure: pre-specified and exploratory subgroup analyses from the TIM-HF trial

BACKGROUND

Meta-analyses have suggested that remote telemedical management (RTM) positively affects clinical outcomes in chronic HF patients. The results of two recent randomised RTM trials do not corroborate these results. We aim to report prospectively defined and exploratory subgroup analyses for the TIM-HF trial and to identify a patient profile that could potentially benefit from RTM for further investigation in randomised clinical trials.

METHODS

In TIM-HF, 710 stable chronic HF patients, in NYHA class II or III with a history of HF decompensation within 2 years previously or a LVEF ≤ 25% were randomly assigned (1:1) to RTM or usual care. The primary outcome was total death and secondary outcomes included days lost due to death or HF hospitalisation and a composite of cardiovascular death and HF hospitalisation. Twelve subgroups were prospectively defined and patient profiling was investigated for the subgroup with a prior history of HF decompensation, an LVEF ≥ 25% and a PHQ-9 score<10.

RESULTS

The subgroup treatment effects were significant for total mortality for the PHQ-9 subgroup only (p for interaction<0.027). For the outcome 'number of days lost due to hospitalisation for HF or death', the subgroup treatment effects were significant (p for interaction<0.05) for patients with a prior HF decompensation or an ICD implant or a PHQ score of <10 and for the patient-profiling subgroup.

CONCLUSIONS

Telemedicine management may not be appropriate for all HF patients. Future research needs to investigate which HF population may benefit from this intervention.

[The value of telemedicine in 2011 : standard care in heart failure therapy?]

Heart failure represents a significant clinical and health economic problem. The implementation of new therapeutic strategies favorably affecting the course of the disease remains insufficient in day to day practice. Thus, the use telemedicine offers a central service and information instrument, such that optimized therapy can be achieved by consistent patient surveillance. Predefined vital parameters are automatically transmitted to the telemedicine center; if individually predefined limits are exceeded, therapeutic means are immediately initiated. The service is available to patients 24 h/day throughout the year in case cardio-pulmonary symptoms are experienced. This patient-oriented use of technology should not replace the physician-patient relationship, but improves and supports the participation and self-management of patients.

Influence of sex on treatment and outcome in chronic heart failure

The population is aging, the prevalence of heart failure increases with age, and on average women live longer than men. There is evidence for sex-specific effects of individual, guideline-recommended drugs used for treatment of chronic heart failure. Women are underrepresented in most clinical trials and only a minority of drug applications to regulatory authorities have included sex analyses. The present review focuses on the potential female survival benefit in heart failure, the influence of sex on medical treatment in a broader sense, and the potential benefit to be derived from guideline recommended treatment and common adjunctive heart failure medication.