Maggioni AP, Anker SD, Dahlström U, et al, on behalf of the Heart Failure Association of the ESC (HFA)
Eur J Heart Fail published 26 August 2013, 10.1093/eurjhf/hft134

Background

Therapeutic approaches for hospitalised patients with heart failure (HF) have changed little over the past decades. Trials have been conducted that have provided evidence on effective treatments that could be included in the recommendations of current guidelines [1-4]. However, treatment guidelines are adopted slowly or implemented inconsistently, thus failing to lead to improvements in patient care quality and outcomes [5-8].
The ESC-HF Pilot Survey showed that the rate of use of renin-angiotensin-aldosterone systemblockers (ACE-inhibitors, ARB and aldosterone blockers) and beta-adrenergic blockers was satisfactory, although the use of appropriate doses was suboptimal [9]. Implantation of devices was often not according to criteria [9]. Similarly, the EUROMED registry showed that the implantation rates of ICD and CRT were increasing over the past decade, but still below expectations based on recommendations [10].
The ESC Long-term Registry aims to evaluate how recommendations of most recent European guidelines are adopted, and if not, why not.

Main results

• Type of i.v. treatment for HF at hospital entry was quite often not according to ESC guidelines, e.g. a substantial number of patients received inotropes even with SBP values > 90 mmHg, and other received i.v. nitrate despite SBP < 100 mmHg. 
• The use of recommended oral treatment had improved at discharge, as compared to the period preceding hospital admission.
• Intended use of ACE inhibitors/ARBs, beta-blockers and MRAs in patients with reduced EF was 92.2%, 92.7% and 67% respectively. In a large majority of cases, reported contra-indications or a documented intolerance were the reason for non-prescription of recommended drugs. Real rates of undertreatment are 3.2%, 2.3% and 5.4% respectively. Less than one-third of patients received the target dosage as indicated by current guidelines. In a third of these cases this was because up-titration was still ongoing, while about the same amount of people the reasons were unclear.
• A majority (62.1%) of patients with an ICD, did not have clinical characteristics that would call for ICD implantation. On the other hand, about 10% of patients had the indication, but were not implanted. Similar figures were seen for implantation of a CRT.

Conclusion

This ESC Long-term registry reveals that currently a large proportion of patients with HF fails to receive the recommended drugs and/or the target dose. However, when taking into account the reasons for non-adherence to guidelines, the real rate of undertreatment or underdosage is acceptable. With regard to the use of oral treatments, this report shows that admission for HF is a concrete opportunity to optimise background therapy.
Device implantation was not significantly modified during or after hospital admission, and showed a greater gap between guidelines and practice.

References

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