Physician perceptions, attitudes, and strategies towards implementing guideline-directed medical therapy in heart failure with reduced ejection fraction. A survey of the Heart Failure Association of the ESC and the ESC Council for Cardiology Practice.
Guideline‐directed medical therapy
Heart failure with reduced ejection fraction
Treatment implementation
Journal
European journal of heart failure
ISSN: 1879-0844
Titre abrégé: Eur J Heart Fail
Pays: England
ID NLM: 100887595
Informations de publication
Date de publication:
22 Mar 2024
22 Mar 2024
Historique:
revised:
14
02
2024
received:
13
01
2024
accepted:
13
03
2024
medline:
22
3
2024
pubmed:
22
3
2024
entrez:
22
3
2024
Statut:
aheadofprint
Résumé
Recent guidelines recommend four core drug classes (renin-angiotensin system/angiotensin receptor-neprilysin inhibitor [RASi/ARNi], beta-blocker, mineralocorticoid receptor antagonist [MRA], and sodium-glucose cotransporter 2 inhibitor [SGLT2i]) for the pharmacological management of heart failure (HF) with reduced ejection fraction (HFrEF). We assessed physicians' perceived (i) comfort with implementing the recent HFrEF guideline recommendations; (ii) status of guideline-directed medical therapy (GDMT) implementation; (iii) use of different GDMT sequencing strategies; and (iv) barriers and strategies for achieving implementation. A 26-question survey was disseminated via bulletin, e-mail and social channels directed to physicians with an interest in HF. Of 432 respondents representing 91 countries, 36% were female, 52% were aged <50 years, and 90% mainly practiced in cardiology (30% HF). Overall comfort with implementing quadruple therapy was high (87%). Only 12% estimated that >90% of patients with HFrEF without contraindications received quadruple therapy. The time required to initiate quadruple therapy was estimated at 1-2 weeks by 34% of respondents, 1 month by 36%, 3 months by 24%, and ≥6 months by 6%. The average respondent favoured traditional drug sequencing strategies (RASi/ARNi with/followed by beta-blocker, and then MRA with/followed by SGLT2i) over simultaneous initiation or SGLT2i-first sequences. The most frequently perceived clinical barriers to implementation were hypotension (70%), creatinine increase (47%), hyperkalaemia (45%) and patient adherence (42%). Although comfort with implementing all four core drug classes in patients with HFrEF was high among physicians, a majority estimated implementation of GDMT in HFrEF to be low. We identified several important perceived clinical and non-clinical barriers that can be targeted to improve implementation.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Informations de copyright
© 2024 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.
Références
Tromp J, Ouwerkerk W, van Veldhuisen DJ, Hillege HL, Richards AM, van der Meer P, et al. A systematic review and network meta‐analysis of pharmacological treatment of heart failure with reduced ejection fraction. JACC Heart Fail 2022;10:73–84. https://doi.org/10.1016/j.jchf.2021.09.004
Turgeon RD, Barry AR, Hawkins NM, Ellis UM. Pharmacotherapy for heart failure with reduced ejection fraction and health‐related quality of life: A systematic review and meta‐analysis. Eur J Heart Fail 2021;23:578–589. https://doi.org/10.1002/ejhf.2141
Savarese G, Carrero JJ, Pitt B, Anker SD, Rosano GMC, Dahlström U, et al. Factors associated with underuse of mineralocorticoid receptor antagonists in heart failure with reduced ejection fraction: An analysis of 11 215 patients from the Swedish Heart Failure Registry. Eur J Heart Fail 2018;20:1326–1334. https://doi.org/10.1002/ejhf.1182
Greene SJ, Tan X, Yeh YC, Bernauer M, Zaidi O, Yang M, et al. Factors associated with non‐use and sub‐target dosing of medical therapy for heart failure with reduced ejection fraction. Heart Fail Rev 2022;27:741–753. https://doi.org/10.1007/s10741‐021‐10077‐x
Stolfo D, Sinagra G, Savarese G. Evidence‐based therapy in older patients with heart failure with reduced ejection fraction. Card Fail Rev 2022;8:e16. https://doi.org/10.15420/cfr.2021.34
Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al.; ESC Scientific Document Group. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016;37:2129–2200. https://doi.org/10.1093/eurheartj/ehw128
McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the diagnosis and treatment of acute and chronic heart failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2012;14:803–869. https://doi.org/10.1093/eurjhf/hfs105
Rosano GMC, Moura B, Metra M, Böhm M, Bauersachs J, Ben Gal T, et al. Patient profiling in heart failure for tailoring medical therapy. A consensus document of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2021;23:872–881. https://doi.org/10.1002/ejhf.2206
Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, et al. 2022 AHA/ACC/HFSA Guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022;145:e895–e1032. https://doi.org/10.1161/CIR.0000000000001063
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2022;24:4–131. https://doi.org/10.1002/ejhf.2333
Packer M, McMurray JJV. Rapid evidence‐based sequencing of foundational drugs for heart failure and a reduced ejection fraction. Eur J Heart Fail 2021;23:882–894. https://doi.org/10.1002/ejhf.2149
McMurray JJV, Packer M. How should we sequence the treatments for heart failure and a reduced ejection fraction?: A redefinition of evidence‐based medicine. Circulation 2021;143:875–877. https://doi.org/10.1161/CIRCULATIONAHA.120.052926
Shen L, Jhund PS, Docherty KF, Vaduganathan M, Petrie MC, Desai AS, et al. Accelerated and personalized therapy for heart failure with reduced ejection fraction. Eur Heart J 2022;43:2573–2587. https://doi.org/10.1093/eurheartj/ehac210
Maddox TM, Januzzi JL Jr, Allen LA, Breathett K, Butler J, Davis LL, et al. 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for optimization of heart failure treatment: Answers to 10 pivotal issues about heart failure with reduced ejection fraction: A report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2021;77:772–810. https://doi.org/10.1016/j.jacc.2020.11.022
Savarese G, Bodegard J, Norhammar A, Sartipy P, Thuresson M, Cowie MR, et al. Heart failure drug titration, discontinuation, mortality and heart failure hospitalization risk: A multinational observational study (US, UK and Sweden). Eur J Heart Fail 2021;23:1499–1511. https://doi.org/10.1002/ejhf.2271
Stolfo D, Lund LH, Benson L, Lindberg F, Ferrannini G, Dahlström U, et al. Real‐world use of sodium‐glucose cotransporter 2 inhibitors in patients with heart failure and reduced ejection fraction: Data from the Swedish Heart Failure Registry. Eur J Heart Fail 2023;25:1648–1658. https://doi.org/10.1002/ejhf.2971
Matan D, Löfström U, Corovic Cabrera C, Eriksson B, Ekström M, Hage C, et al. Reorganization of heart failure management and improved outcome – the 4D HF Project. Scand Cardiovasc J 2021;55:1–8. https://doi.org/10.1080/14017431.2020.1820075
Stolfo D, Lund LH, Becher PM, Orsini N, Thorvaldsen T, Benson L, et al. Use of evidence‐based therapy in heart failure with reduced ejection fraction across age strata. Eur J Heart Fail 2022;24:1047–1062. https://doi.org/10.1002/ejhf.2483
Savarese G, Kishi T, Vardeny O, Adamsson Eryd S, Bodegård J, Lund LH, et al. Heart failure drug treatment‐inertia, titration, and discontinuation: A multinational observational study (EVOLUTION HF). JACC Heart Fail 2023;11:1–14. https://doi.org/10.1016/j.jchf.2022.08.009
Schrage B, Lund LH, Benson L, Braunschweig F, Ferreira JP, Dahlström U, et al. Association between a hospitalization for heart failure and the initiation/discontinuation of guideline‐recommended treatments: An analysis from the Swedish Heart Failure Registry. Eur J Heart Fail 2023;25:1132–1144. https://doi.org/10.1002/ejhf.2928
D'Amario D, Rodolico D, Rosano GMC, Dahlström U, Crea F, Lund LH, et al. Association between dosing and combination use of medications and outcomes in heart failure with reduced ejection fraction: Data from the Swedish Heart Failure Registry. Eur J Heart Fail 2022;24:871–884. https://doi.org/10.1002/ejhf.2477
Savarese G, Lund LH, Dahlström U, Strömberg A. Nurse‐led heart failure clinics are associated with reduced mortality but not heart failure hospitalization. J Am Heart Assoc 2019;8:e011737. https://doi.org/10.1161/JAHA.118.011737
Mebazaa A, Davison B, Chioncel O, Cohen‐Solal A, Diaz R, Filippatos G, et al. Safety, tolerability and efficacy of up‐titration of guideline‐directed medical therapies for acute heart failure (STRONG‐HF): A multinational, open‐label, randomised, trial. Lancet 2022;400:1938–1952. https://doi.org/10.1016/S0140‐6736(22)02076‐1
Fauvel C, Bonnet G, Mullens W, Giraldo CIS, Mežnar AZ, Barasa A, et al. Sequencing and titrating approach of therapy in heart failure with reduced ejection fraction following the 2021 European Society of Cardiology guidelines: An international cardiology survey. Eur J Heart Fail 2023;25:213–222. https://doi.org/10.1002/ejhf.2743
Packer M. Are the benefits of SGLT2 inhibitors in heart failure and a reduced ejection fraction influenced by background therapy? Expectations and realities of a new standard of care. Eur Heart J 2020;41:2393–2396. https://doi.org/10.1093/eurheartj/ehaa344
Felker GM, Ellison DH, Mullens W, Cox ZL, Testani JM. Diuretic therapy for patients with heart failure: JACC state‐of‐the‐art review. J Am Coll Cardiol 2020;75:1178–1195. https://doi.org/10.1016/j.jacc.2019.12.059
Cautela J, Tartiere JM, Cohen‐Solal A, Bellemain‐Appaix A, Theron A, Tibi T, et al. Management of low blood pressure in ambulatory heart failure with reduced ejection fraction patients. Eur J Heart Fail 2020;22:1357–1365. https://doi.org/10.1002/ejhf.1835
Savarese G, Xu H, Trevisan M, Dahlström U, Rossignol P, Pitt B, et al. Incidence, predictors, and outcome associations of dyskalemia in heart failure with preserved, mid‐range, and reduced ejection fraction. JACC Heart Fail 2019;7:65–76. https://doi.org/10.1016/j.jchf.2018.10.003
Trevisan M, Fu EL, Xu Y, Savarese G, Dekker FW, Lund LH, et al. Stopping mineralocorticoid receptor antagonists after hyperkalaemia: Trial emulation in data from routine care. Eur J Heart Fail 2021;23:1698–1707. https://doi.org/10.1002/ejhf.2287
Butler J, Anker SD, Lund LH, Coats AJS, Filippatos G, Siddiqi TJ, et al. Patiromer for the management of hyperkalemia in heart failure with reduced ejection fraction: The DIAMOND trial. Eur Heart J 2022;43:4362–4373. https://doi.org/10.1093/eurheartj/ehac401
Weir MR, Bakris GL, Bushinsky DA, Mayo MR, Garza D, Stasiv Y, et al.; OPAL‐HK Investigators. Patiromer in patients with kidney disease and hyperkalemia receiving RAAS inhibitors. N Engl J Med 2015;372:211–221. https://doi.org/10.1056/NEJMoa1410853
Pitt B, Anker SD, Bushinsky DA, Kitzman DW, Zannad F, Huang IZ; PEARL‐HF Investigators. Evaluation of the efficacy and safety of RLY5016, a polymeric potassium binder, in a double‐blind, placebo‐controlled study in patients with chronic heart failure (the PEARL‐HF) trial. Eur Heart J 2011;32:820–828. https://doi.org/10.1093/eurheartj/ehq502
Anker SD, Kosiborod M, Zannad F, Piña IL, McCullough PA, Filippatos G, et al. Maintenance of serum potassium with sodium zirconium cyclosilicate (ZS‐9) in heart failure patients: Results from a phase 3 randomized, double‐blind, placebo‐controlled trial. Eur J Heart Fail 2015;17:1050–1056. https://doi.org/10.1002/ejhf.300
Ferreira JP, Zannad F, Pocock SJ, Anker SD, Butler J, Filippatos G, et al. Interplay of mineralocorticoid receptor antagonists and empagliflozin in heart failure: EMPEROR‐Reduced. J Am Coll Cardiol 2021;77:1397–1407. https://doi.org/10.1016/j.jacc.2021.01.044
Scalvini S, Bernocchi P, Villa S, Paganoni AM, La Rovere MT, Frigerio M. Treatment prescription, adherence, and persistence after the first hospitalization for heart failure: A population‐based retrospective study on 100 785 patients. Int J Cardiol 2021;330:106–111. https://doi.org/10.1016/j.ijcard.2021.02.016
Joseph P, Roshandel G, Gao P, Pais P, Lonn E, Xavier D, et al.; Polypill Trialists' Collaboration. Fixed‐dose combination therapies with and without aspirin for primary prevention of cardiovascular disease: An individual participant data meta‐analysis. Lancet 2021;398:1133–1146. https://doi.org/10.1016/S0140‐6736(21)01827‐4
Castellano JM, Cordero A, Fuster V. Polypill strategy in secondary cardiovascular prevention. N Engl J Med 2022;387:2197–2198. https://doi.org/10.1056/NEJMc2213446
Pandey A, Keshvani N, Wang TJ. Should polypills be used for heart failure with reduced ejection fraction? Circulation 2022;146:276–278. https://doi.org/10.1161/CIRCULATIONAHA.122.059661
Malmborg M, Assad Turky Al‐Kahwa A, Kober L, Torp‐Pedersen C, Butt JH, Zahir D, et al. Specialized heart failure clinics versus primary care: Extended registry‐based follow‐up of the NorthStar trial. PLoS One 2023;18:e0286307. https://doi.org/10.1371/journal.pone.0286307
Lindberg F, Lund LH, Benson L, Schrage B, Edner M, Dahlström U, et al. Patient profile and outcomes associated with follow‐up in specialty vs. primary care in heart failure. ESC Heart Fail 2022;9:822–833. https://doi.org/10.1002/ehf2.13848