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Wednesday, July 25, 2018

CHAMP-HF: Heart Failure Treatment in US Remains Subpar

CHAMP-HF: Heart Failure Treatment in US Remains Subpar

CHAMP-HF: Heart Failure Treatment in US Remains Subpar

Major gaps remain in use and dosing of evidence-based, guideline-recommended medications for heart failure with reduced ejection fraction (HFrEF), according to a new analysis of data from the Change the Management of Patients with Heart Failure (CHAMP-HF) registry.

"Even in the absence of any new heart failure therapies being discovered, if the existing guideline-recommended medical therapies were optimally implemented and dosed, tens of thousands of additional deaths in patients with heart failure could be avoided each year," senior author Gregg Fonarow, MD, University of California, Los Angeles, told theheart.org | Medscape Cardiology.

"Despite a robust database and well-articulated clinical practice guidelines, the findings from the CHAMP-HF registry demonstrate the care deficit that still needs to be addressed," said Clyde Yancy, MD, Northwestern University Feinberg School of Medicine in Chicago, Illinois, who wasn't involved in the study.

The study was published online July 16 in the Journal of the American College of Cardiology.

There is substantial opportunity to improve care and outcomes for patients with heart failure with reduced ejection fraction. Dr Gregg Fonarow

The investigators, led by Stephen J. Greene, MD, Duke Clinical Research Institute, Durham, North Carolina, examined data from 3518 outpatients with HFrEF (mean EF, 29%) receiving at least one oral medication for management of HF from 150 primary care and cardiology practices across the United States. Their mean age was 66 years, and 29% were women.

Among patients eligible to receive medication, 27% were not prescribed an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker/angiotensin receptor–neprilysin inhibitor, 33% didn't get a β-blocker, and 67% were not prescribed a mineralocorticoid receptor antagonist, the researchers found.

Even when patients did receive recommended medications, they generally received the medications at a dose lower than the recommended target dose. Fewer than one in four eligible patients were receiving all three guideline-recommended drug types, and only 1% were receiving the target dose of all three medications, the researchers found.

Factors associated with lower medication use or dose were older age, lower blood pressure, more severe functional heart class, renal insufficiency, and recent HF hospitalization. Social and economic characteristics were not independently associated with medication use or dose.

"As these medications have been demonstrated to improve health status, quality of life, reduce the need for hospitalization, and mortality when provided at recommended doses, these findings suggest that there is substantial opportunity to improve care and outcomes for patients with heart failure with reduced ejection fraction," Fonarow told theheart.org | Medscape Cardiology.

"There is a compelling need for multifaceted quality improvement systems to be implemented in every setting in which patients with heart failure receive care. These systems have been shown to help improve the use and dosing of guideline-directed medical therapies and, in turn, improve outcomes," he said.

Fonarow also noted that traditional measures to assess quality of care have focused on whether eligible patients were treated with a class of medication (yes vs no). "These findings suggest that new quality measures that also focus on whether there was adequate dosing of the medication, in the absence of contraindications or intolerance of higher doses, may also be useful," he said.

Sobering but Not Surprising

The finding that only 1% of patients with HFrEF with clear eligibility for all classes of guideline-directed medical therapy (GDMT) were receiving indicated therapies at the appropriate doses is "sobering but not unexpected because the translation of evidence into practice, ie, implementation science, remains a still nascent and poorly informed process," Yancy told theheart.org | Medscape Cardiology.

"As well, the exigencies of clinical practice — access to medical care, appropriate insurance for drug benefits, absolute and relative contraindications, and importantly patient preferences — all serve as rate-limiting steps," Yancy explained. While tools to support the guidelines and the construct of optimal medical regimens for HFrEF have been developed and are readily available, "there is much more that needs to be explored and developed to effectuate ideal implementation" of guideline-directed care for HF, he said.

"We and others have demonstrated clearly that doing the right thing for the right patient at the right time and in the right manner yields lives saved and hospitalizations prevented. That should be sufficient for us to be ever diligent in our quest to improve the quality of care for heart failure," said Yancy.

John L. Jefferies, MD, MPH, The Heart Institute, Cincinnati Children's Hospital Medical Center, Ohio, and Nasrien E. Ibrahim, MD, Massachusetts General Hospital, Boston, are also not particularly surprised by the findings of Fonarow and colleagues.

Despite published clinical practice guidelines, adoption of such therapies with established survival benefit "continue[s] to be dismally low and show[s] no significant improvement over the last 8 years," they note in a related editorial titled, "Are Guidelines Merely Suggestions?"

Jefferies and Ibrahim say efforts to improve uptake of GDMT among patients with HFrEF should be aimed at the clinician, the patient, and the system factors that contribute to "clinical or therapeutic inertia. If we can address the clinician, patient, and system factors that are modifiable…we can improve the implementation of GDMT and, in turn, reduce the morbidity and mortality associated with HF," they predict.

"[J]ust as stop signs are not merely suggestions for drivers at intersections, neither are published guidelines for clinicians managing patients with HF," they conclude.

CHAMP-HF was supported by Novartis Pharmaceuticals. Fonarow has consulted for Amgen, Bayer, Medtronic, and Novartis. Greene has received support from a National Institutes of Health grant, the Heart Failure Society of America/Emergency Medicine Foundation Acute Heart Failure Young Investigator award funded by Novartis, and Novartis. Jefferies has consulted for Bayer, Novartis, and Sanofi Genzyme and has received grants from Medtronic. Ibrahim is supported in part by the Dennis and Marilyn Barry Fellowship in Cardiology. Yancy has no relevant disclosures.

J Am Coll Cardiol. Published online July 16, 2018. Abstract, Editorial

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