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HF guideline-recommended therapies increased survival benefits
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A combination of several key guideline-recommended therapies for treatment of patients with HF and reduced left ventricular ejection fraction decreased the risk for 24-month mortality, according to an analysis of IMPROVE HF data.
Utilizing data from the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) trial, researchers selected 4,128 patients with a clinical diagnosis of HF or prior MI documented on at least two separate visits through a propensity score matching process. At 24 months, 1,376 patients (mean age, 72 years; 71.2% men) died and were enrolled as cases, and 2,752 alive patients (mean age, 71.6 years; 72.2% men) were enrolled as controls.
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The IMPROVE HF steering committee selected seven guideline-recommended therapies during trial design:
- ACE inhibitor or angiotensin receptor blocker.
- Beta-blocker.
- Aldosterone antagonist.
- Anticoagulation for atrial fibrillation or atrial flutter.
- Cardiac resynchronization therapy with a pacemaker or defibrillator.
- Implantable cardioverter defibrillator.
- Patient education about HF.
“We performed a nested case-control study to look at each of the individual guideline-recommended therapies and their incremental benefit and whether there were cumulative benefits that come from using combinations of the evidence-based HF therapy,” Gregg C. Fonarow, MD, professor of CV medicine at the University of California, Los Angeles, told Cardiology Today.
Overall, Fonarow and colleagues found beta-blocker (adjusted OR for death=0.42; 95% CI, 0.34-0.52) and cardiac resynchronization therapy (adjusted OR for death=0.44; 95% CI, 0.29-0.67) were associated with the greatest 24-month survival benefit. ACE inhibitors, angiotensin receptor blockers, ICD, anticoagulation for AF and HF education also showed survival benefit.
“The one therapy that did not have a significant association with survival benefit was aldosterone antagonist,” Fonarow said. “However, these agents have been shown to be very beneficial in clinical trials, so additional study and replication will be warranted before concluding there’s a difference between the clinical effectiveness of the agent vs. the efficacy that’s been shown in clinical trials.”
The researchers found incremental benefits when more than one therapy was used. When only beta-blockers were prescribed, patients’ odds for 2-year survival improved 39%. The odds increased to 81% to 90% as therapies were added, plateauing at four to five therapies (adjusted OR=0.31; 95% CI, 0.23-0.42 for 5 or more vs. 0/1).
“These results provide further evidence supporting current guideline recommendations regarding key evidence-based therapies for patients with HF and reduced ejection fraction,” Fonarow said. “It provides also a further rationale for using systems performance improvement programs and HF disease management programs to ensure the implementation of these guideline-recommended therapies in practice.” – by Casey Murphy
For more information:
Disclosure: Dr. Fonarow is a consultant for Medtronic and Novartis and has received honoraria from Medtronic.
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This research once again stresses the importance of methodically applying evidence-based care to an outpatient population with HF and low ejection fraction. The elegant analysis from the IMPROVE HF cohort confirms the selection of these medical and device therapies with an impressive message. Systems, hospitals and groups must develop processes of care that directly address the continuing gap between practice and evidence-based care. Collaborative or team care can enhance the clinician's ability to achieve these goals. Our patients deserve it.
– Ileana L. Piña, MD
Cardiology
Today Editorial Board member
Disclosure: Dr. Piña reports no relevant financial disclosures.