Research Article
Volume 2 Issue 3 - 2016
Adherence to Guideline-Directed Medical Therapy in Patients with Heart Failure with Reduced Ejection Fraction in Shahid Gangalal National Heart Centre, Kathmandu, Nepal
Chandra Mani Adhikari*, Reeju Manandhar, Dipanker Prajapati, Murari Dhungana, Amrit Bogati and Rishikesh Rijal
Department of Cardiology, Shahid Gangalal National Heart Centre, Nepal
*Corresponding Author: Chandra Mani Adhikari, Department of Cardiology, Shahid Gangalal National Heart Centre, Bansbari, Kathmandu, Nepal.
Received: June 04, 2016; Published: June 28, 2016
Citation: Chandra Mani Adhikari., et al. “Adherence to Guideline-Directed Medical Therapy in Patients with Heart Failure with Reduced Ejection Fraction in Shahid Gangalal National Heart Centre, Kathmandu, Nepal”. EC Cardiology 2.3 (2016): 152-156.
Abstract
Background and Aims: Heart Failure(HF) with reduced Ejection Fraction (HFrEF) is defined as the clinical diagnosis of HF and left ventricular ejection fraction (LVEF) ≤ 40% also referred to as systolic HF. Guideline-directed medical therapy (GDMT) has shown to reduce mortality for HFrEF. We aim to evaluate adherence to GDMT treatment in our Centre.
Methods: Medical records of 422 with HFrEF patients discharged from our centre in between January 2014 to December 2014 were retrospectively reviewed. Performa was designed to collect patient information which included; age, gender, NYHA functional class at the time of admission, total hospital stay, Left Ventricular Internal Diameter, Left Atrial size, LVEF, Systolic, diastolic blood pressure, heart rate at the time of discharge, creatinine and the drugs used at the time of discharge were recorded.
Results: Among the 422 patients included in this study, 232 (54.9%) were males and 190 (45.1%) were females. The mean age was 63.4 ± 15.5 years. Most of the patients were in NYHA class IV (65.6%), and in Sinus rhythm (78.5%). Among the discharged patients’ diuretic, Angiotensin converting enzyme inhibitor (ACEI)/Angitensin receptor blocker (ARB), β-blocker, Aldosterone Antagonist, and digoxin were prescribed in 100, 86.7, 28.4, 83.9 and 47.9% patients respectively.
Conclusion: ACEI/ARB, diuretic, aldosterone antagonist and digoxin used in HFrEF comparable to international studies. Use of β-blocker is not comparable to international studies. We still need some effort to increase improve our prescription rate of β-blockers.
Keywords: ACEI; ARB; Aldosterone antagonist; β-blocker; Guideline-directed medical therapy (GDMT); Heart Failure with reduced Ejection Fraction (HFrEF)
Introduction
Heart Failure with reduced Ejection Fraction (HFrEF) is defined as the clinical diagnosis of Heart Failure (HF) and Left ventricle ejection fraction(LVEF) ≤ 40%. Also referred to as systolic HF. Guideline-directed medical therapy (GDMT) has shown to reduce mortality for HFrEF. These medications include Angitensin converting enzyme inhibitor (ACEI)/Angitensin receptor blocker (ARB), β-blocker and Aldosterone antagonist (AA). Digoxin can be beneficial in these patients to decrease Hospitalizations whereas Diuretics are recommended to improve symptoms [1].
Adherence to GDMT influences HF outcome positively [2,3]. Physician-adherence to GDMT is one strategy to improve the dismal outcome in HF [4]. Multiple publications on physician-adherence to HF guidelines attest to its growing importance [5,6]. Such studies have consistently uncovered variations and potential disparities in the care of HF patients [2,5,7,8]. We aim to evaluate adherence to GDMT treatment in our centre.
Methods
It was a retrospective, single centre study, performed at Shahid Gangalal National Heart Centre, Bansbari, Kathmandu, Nepal. Discharge summaries of 422 patients who were diagnosed as a case of HFrEF who were admitted for the first time and were discharged in between January 2014 to December 2014 were retrospectively reviewed.
Patients with the diagnosis of acute or old Myocardial Infarction, Ischaemic heart diseases, valvular heart disease were excluded. In case of multiple admissions last discharge will be included. Performa was designed to collect patient information which included; age, gender, NYHA functional class at the time of admission, total hospital stay (days), left ventricle internal diameter in diastole (LVID). Systolic and diastolic blood pressure at the time of discharge, heart rate at the time of discharge, creatinine (Cr) and the drugs used at the time of discharge were recorded.
All the variables were entered into the Statistical Package for Social Sciences software, version 16 (SPSS Inc) for data analysis. Descriptive statistics were computed and presented as means and standard deviations for continuous variables like age and LVEF, categorical variables were reported in percentages.
Results
Among the 422 patient included in this study male and female were almost equal in number. The mean age was 63.4 ± 15.5 years. Most of the patients 331 (78.5%) were in sinus rhythm. Most patient 277 (65,6%) were admitted for NYHA class IV heart failure. Median hospital stay was 5.3 ± 2.7 days. Clinical characteristics and features are shown in Table 1 and table 2.
Characteristic n %
Male
232 54.9
Female
190 45.1
Sinus Rhythm
331 78.5
Atrial fibrillation
70 16.6
Pacemaker
21 4.9
NYHA II
90 21.3
NYHA III
55 13.1
NYHA IV
277 65.6
Heart rate≤60
23 5.4
Systolic BP≤90 (mmHg)
124 29.4
Cr>225 (μmol/L)
11 26

Table 1: Clinical characteristics.

Demographics Mean + SD
Age (years)
63.4 ± 15.5
Hospital Stay (days)
5.3 ± 2.7
NYHA (class)
3.4 ± 0.8
LVID (cm)
6.2 ± 0.8
Left Atrial rise (cm)
4.3 ± 0.6
LVEF (%)
24.7 ± 7.1
Systolic blood pressure (mmHg)
103.8 ± 15.3
Diastolic blood pressure (mmHg)
68.1 ± 9.1
Heart rate<60 (bpm)
79.1 ± 11.6
Cr (μmol/L)
101.4 ± 41.7

Table 2: Clinical features.

In our study Diuretic (100%), was the most commonly used followed by ACEI or ARB (86.7%), AA (83.9%), digoxin (47.9%) and β-blocker (28.4%) as shown in table 3.
Drugs   No. of patients % Mean Dose
ACEI
Enalapril 225 53.3 3.4 ± 1.8 mg
Ramipril 17 4.0 3.6 ± 2.5
ACEI total
  242 57.3  
ARB
Losartan 114 27.0 34.9 ± 15.2 mg
Telmisartan 10 2.4 32.0 ± 10.2
ARB total
  124 29.4  
ACEI+ARB
  366 86.7  
β-blocker
Carvedilol 75 17.8 9.1 ± 9.0 mg
Metoprolol 20 4.7 22.5 ± 5.1 mg
Bisoprolol 25 5.9 2.6 ± 1.1 mg
β-blocker
  120 28.4  
Diuretics
Frusemide 385 91.2 63.2 ± 22.5 mg
Torsemide 37 8.8 44.8 ± 20.3 mg
Diuretics
  422 100  
Aldosterone Antagonist
Spironolactone 352 83.4 28.3±10.3
Epeleronone 2 0.5 37.5 ± 17.6
  354 83.9  
Digoxin
  202 47.9 0.13 ± 0.03
ACEI+ β blocker+ AA
  84 19.9  

Table 3: Table 3: Drugs used
All the three anti HF drugs β-blocker, ACEI or ARB and AA were prescribed in 84 (19.9%) patients.

Discussion
GDMT in HF reduces morbidity and mortality. This has been emphasized in all international practice guidelines. In our study ACEI or ARB was prescribed in 86.7% patients. This prescription rate is better than the study done in (51.4%) Pakistan [9] and (69%) India [10] almost equal to the prescription rate in (83%) Nigeria [11], South Africa (79%) [12]. Interestingly, ours was higher than the ACEI/ARB adherence noted in Japan [2] and rural Australia [6]. In our study, adherence to β-blocker was 28.4% which is lower than, (34%) rural Australia and (48%) in Nigeria [11], but much lower than (57.8%) Japan [2] and (78%) South Africa [12]. But our adherence rate is better than in Pakistan [9] 35.9% and in rural Australia 34% [6].
AA was used in 83.9% patients in our study it is better than the study done in (46.9%) Pakistan [9], (41%) Nigerian [11], (79%) South Africa [12] and (17%) Indian study [10].
Digoxin use in our study was 47.9%, it uses varies a lot, in a study done in Pakistan [9] it was 75 %, (82%) Nigerian study [11], (67%) South African Study [12] and (27%) in Indian study [10].
Diuretics remain the first line of treatment of edema or volume overload particularly in patients of HF. Diuretics reduce pulmonary edema and venous congestion, diuretics (75%). Frusemide (91.2%) is the most commonly used diuretic followed by torsemide in 8.8% patients. In an Indian study [10] 91% of patients received Furosemide, 25% of patients received Torsemide.
A study done by Shore., et al. in US which included 92,361 ischaemic cardiomyopathy patients and 63,652 non-ischemia Cardiomyopathy patients showed that ACEI was used in 90.7% vs 93%, β-blocker in 94.9% VS 93.9% and AA in 31.4% vs 34.5% patients [13]. In a study done in Six European countries (France, Germany, Italy, The Netherlands, Spain, and UK). ACEI (88%), diuretics (82%), cardiac glycosides (52%), β-blockers (58%), and AA (36%) were prescribed [3]. Our AA prescription rate was better than these two studies. In other medication we need some more effort to improve our self.
Despite concrete data to support the use of GDMT in all stages of HF there is considerable variation in the prescription of these therapies in patients with HF. Multiple factors influence the prescription of ß- blockers including concerns regarding advanced age, low LVEF, bradycardia, low BP; these may be the very people who stand to benefit from the GDMT [14]. Similarly ACEI and AA are known to be under prescribed due to concerns regarding renal function and sometimes for no discernible reasons [15,16]. In our study only 5.9% patient had heart rate less than 60 bpm, Cr more than 225 was present in 11 patient. Low BP which means systolic BP of less than 90 mmHg was present in 29.4% patients. Though contraindication to ACEI/ARB, β-blocker and AA are present in our study but lower prescription of β-blocker compared to studies done in other country cannot be explained just to contraindication.
The limitations of this study are; it is a retrospective, observational, non-randomized study that depends only on the data of a single centre. However, this study provides valuable reflection of our day to day practices.
Conclusion
ACEI/ARB, diuretic, AA and digoxin used in HFrEF comparable to international studies. Use of β-blocker is not comparable to international studies. We still need some effort to increase improve our prescription rate of β-blockers.
Bibliography
  1. Clyde W., et al. “ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines”. Journal of the American College of Cardiology 62.16 (2013): 1495-1539.
  2. Ohsaka T., et al. “Clinical impact of guidelines on outcomes in CHF in Japan”. International Heart Journal 49.1 (2008): 59-73.
  3. Komajda M., et al. “Adherence to guidelines is a predictor of outcome in CHF: the MAHLER Survey”. European Heart Journal 26.16 (2005): 1653-1659.
  4. Calvin JE., et al. “Adherence to evidence-based guidelines for heart failure in physicians and their patients: lessons from the heart failure adherence retention trial (HART)”. Congestive Heart Failure 18.2 (2012): 72-78.
  5. Shoukat S., et al. “Adherence to ESC Guidelines for CHF - a national survey of cardiologists in Pakistan”. BMC Cardiovascular Diseases 11 (2011): 68-73.
  6. Yao D., et al. “Adherence to treatment guidelines in the pharmacological management of congestive heart failure in an Australia population”. Journal of Geriatric Cardiology 8.2 (2011): 88-92.
  7. Mbakwem AC and Ajuluchukwu JNA. et al. “Perception of Nigerian Internal Medicine residents on the diagnosis and management of heart failure”. Nigerian Postgraduate Medical Journal On Web 14.4 (2007): 336-340.
  8. Kahn LS., et al. “Facilitating quality improvement in physician management of co-morbid chronic disease in an urban minority practice”. Journal of the National Medical Association 99.4 (2007): 377-383.
  9. Hussain S., et al. “Optimal medical therapy in chronic heart failure”. Pakistan Heart Journal 47.3 (2014): 127-131.
  10. Prasanna Kumar B., et al. “Drug Utilization Study in Congestive Heart Failure at a Tertiary Care Hospital. Scholars Journal of Applied Medical Sciences 3.2E (2015): 857-862.
  11. Janet N Ajuluchukwu., et al. “Physician-adherence to pharmacotherapy guidelines for chronic heart failure in a tertiary health facility in Lagos, Nigeria”. Journal of Hospital Administration 3.2 (2014): 32-41.
  12. Ruf V., et al. “Medication adherence, self-care behavior, and knowledge on heart failure in urban South Africans: Heart of Soweto Studies”. Cardiovascular Journal of Africa 21.2 (2010): 86-92.
  13. Supriya Shore., et al. “Characteristics, Treatments, and Outcomes of Hospitalized Heart Failure Patients Stratified by Etiologies of Cardiomyopathy”. JACC: Heart failure 3.11 (2015): 906-916.
  14. Yilmaz MB.,et al. “Prescription patterns in patients with systolic heart failure at hospital discharge: why beta blockers are under prescribed or prescribed at low dose in real life?” International Journal of Clinical Practice 61.2 (2007): 225-230.
  15. Bart BA., et al. “Reasons for underuse of angiotensin-converting enzyme inhibitors in patients with heart failure and left ventricular dysfunction”. American Journal of Cardiology 79.8 (1997): 1118-1120.
  16. Samuel JL and Delcayre C. “Heart failure: aldosterone antagonists are underused by clinicians”. Nature Reviews Cardiology 7.3 (2010): 125-127.
Copyright: © 2016 Chandra Mani Adhikari., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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