Nurse-coordinated collaborative disease management improves the quality of guideline-recommended heart failure therapy, patient-reported outcomes, and left ventricular remodelling.

Heart failure (HF) pharmacotherapy is often not prescribed according to guidelines. This longitudinal study investigated prescription rates and dosages of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), beta-blockers, and mineralocorticoid receptor antagonists (MRA), and concomitant changes of symptoms, echocardiographic parameters of left ventricular (LV) function and morphology and results of the Short Form-36 (SF-36) Health Survey in participants of the Interdisciplinary Network Heart Failure (INH) programme. The INH study evaluated a nurse-coordinated management, HeartNetCare-HF(TM) (HNC), against Usual Care (UC) in patients hospitalized for decompensated HF [LV ejection fraction (LVEF) ≤40% before discharge). A total of 706 subjects surviving >18 months (363 UC, 343 HNC) were examined 6-monthly. At baseline, 92% received ACEi/ARB, (HNC/UC 91/93%, P = 0.28), 86% received beta-blockers (86/86%, P = 0.83), and 44% received MRA (42/47%, P = 0.07). After 18 months, beta-blocker use had increased only in HNC (+7.6%, P < 0.001). Guideline-recommended target doses were achieved more frequently in HNC for ACEi/ARB (HNC/UC: 50/25%, P < 0.001) and beta-blockers (39/15%, P < 0.001). The following variables were more improved and/or better in subjects undergoing HNC compared with UC: LVEF (47 ± 12 vs. 44 ± 12%, P = 0.004, change +17/+14%, P = 0.010), LV end-diastolic diameter (59 ± 9 vs. 61 ± 9.6 mm, P = 0.024, change -2.3/-1.4 mm, P = 0.13), New York Heart Association class (1.9 ± 0.7 vs. 2.1 ± 0.7, P = 0.001, change -0.44/-0.25, P = 0.002) and SF-36 physical component summary score (41.6 ± 11.2 vs. 38.5 ± 11.8, P = 0.004, change +3.3 vs. +1.1 score points, P < 0.02). Prescription rates and dosages of ACEi/ARB and beta-blockers improved more in HNC than UC patients. Concomitantly, participation in HNC was associated with significantly better clinical outcomes and more favourable echocardiographic changes after 18 months.

Güder G ，Störk S ，Gelbrich G ，Brenner S ，Deubner N ，Morbach C ，Wallenborn J ，Berliner D ，Ertl G ，Angermann CE ... -  《-》

Optimization of heart FailUre medical Treatment after hospital discharge according to left ventricUlaR Ejection fraction: the FUTURE survey.

No clinical practice guidelines are available for the treatment of heart failure (HF) in patients with preserved left ventricular ejection fraction (LVEF). To determine how cardiologists manage medical treatment in HF patients after hospital discharge, according to LVEF. The FUTURE study was a cross-sectional survey conducted in HF outpatients by French private cardiologists between September 2007 and August 2008. Patients had to have been hospitalized within the previous 18 months with a diagnosis of HF. Clinical data and HF treatments (angiotensin-converting enzyme inhibitors [ACEIs], angiotensin receptor blockers [ARBs], beta-blockers, diuretics and aldosterone antagonists) were recorded retrospectively, with precise information on drug doses, at two successive time points (at hospital discharge and at the index consultation). HF treatment was compared in patients with reduced (less than or equal to 40%) versus preserved (more than 40%) LVEF. Completed data were available for 1137 HF patients enrolled by 424 cardiologists. Mean patient age was 72±11 years; LVEF was reduced in 56% and preserved in 44%. The therapeutic approach was similar in the two groups, both at hospital discharge and at the index consultation. At the index consultation, HF treatment was: beta-blocker (74%); ACEI/ARB (83%); loop diuretic (86%); aldosterone antagonist (31%). The majority of patients (62%) received a beta-blocker plus an ACEI or an ARB; 56% reached more than or equal to 50% of the target dose for each treatment. There were no major differences in treatments and dosages between the groups with low and preserved LVEF. In 15% of cases where the drug dose was not increased, fear of adverse events was reported as the reason. The FUTURE survey showed a similar approach to HF treatment irrespective of LVEF. Compared with previous studies, we saw an improvement in the use of recommended HF drugs, especially beta-blockers. However, achievement of target doses could be improved.

Cohen Solal A ，Leurs I ，Assyag P ，Beauvais F ，Clerson P ，Contre C ，Thebaut JF ，Genoun M ，French National College of Cardiologists ... -  《-》

Prescribing patterns of evidence-based heart failure pharmacotherapy and outcomes in the ASIAN-HF registry: a cohort study.

Angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), β blockers, and mineralocorticoid receptor antagonists (MRAs) are of proven benefit and are recommended by guidelines for management of patients with heart failure and reduced ejection fraction (HFrEF). We aimed to examine the first prospective multinational data from Asia on prescribing patterns of guideline-directed medical therapies and analyse its effect on outcomes. In the prospective multinational ASIAN-HF registry (with enrolment from 46 centres in 11 countries in Asia), we enrolled patients aged 18 years or older, with symptomatic heart failure (stage C, with at least one episode of decompensated heart failure in the past 6 months that resulted in admission to hospital or was treated in an outpatient clinic) and left ventricular systolic dysfunction (ejection fraction ≤40% on baseline echocardiography, consistent with 2016 European Society of Cardiology guidelines). We excluded patients with heart failure caused by severe valvular heart disease, life-threatening comorbidity with a life expectancy of less than 1 year, who were unable or unwilling to give consent, or who had concurrent participation in a clinical trial. Patients were followed up for 3 years for the outcomes of death and cause-specific admittance to hospital. Primary outcomes were uptake of guideline-directed medical therapies (as proportions) by therapeutic class, achieved doses as proportions of guideline-recommended doses, and their association with 1-year composite outcome of all-cause death or admittance to hospital because of heart failure. This study is registered with ClinicalTrials.gov, number NCT01633398. Between Oct 1, 2012, and Dec 31, 2015, we enrolled 5276 patients with HFrEF (mean age 59·6 years [SD 13·2], 77% men, body-mass index 24·9 kg/m2 [5·1], 33% New York Heart Association class III or IV). Follow-up data were available for 4544 (90%) of 5061 eligible patients taking medication for heart failure, with median follow-up of 417 days (IQR 214-735). ACE inhibitors or ARBs were prescribed to 3868 (77%) of 5005 patients, β blockers to 3975 (79%) of 5061, and MRAs to 2998 (58%) of 5205, with substantial regional variation. Guideline-recommended dose was achieved in only 17% of cases for ACE inhibitors or ARB, 13% for β blockers, and 29% for MRAs. Country (all three drug classes), increasing body-mass index (ACE inhibitors or ARBs and MRAs), and in-patient recruitment (ACE inhibitors or ARBs and β blockers) were associated with attainment of guideline-recommended dose (all p<0·05). When adjusted for indication bias, increasing drug doses, from low dose (1-<25% of guideline-recommended dose) upwards were associated with lower hazards of a 1-year composite outcome for ACE inhibitors or ARBs and β blockers compared with non-users. The lowest adjusted hazards were in the group that attained guideline-recommended doses above 50% (hazard ratio [HR] 0·54, 95% CI 0·50-0·58 for ACE inhibitors or ARBs [50-99·9%]; HR 0·47, 0·46-0·50 for β blockers, and HR 0·77, 0·72-0·81 for MRAs [≥100%]). Guideline-directed medical therapies at recommended doses are underutilised in patients with HFrEF. Improved uptake and uptitration of guideline-directed medical therapies are needed for better patient outcomes. National Medical Research Council (Singapore), A*STAR Biomedical Research Council ATTRaCT program, Boston Scientific Investigator Sponsored Research program, and Bayer.

Teng TK ，Tromp J ，Tay WT ，Anand I ，Ouwerkerk W ，Chopra V ，Wander GS ，Yap JJ ，MacDonald MR ，Xu CF ，Chia YM ，Shimizu W ，ASIAN-HF investigators ，Richards AM ，Voors A ，Lam CS ... -  《Lancet Global Health》

Gap between guidelines and clinical practice in heart failure with reduced ejection fraction: Results from TSOC-HFrEF registry.

Heart failure (HF) is a global health problem. Guidelines for the management of HF have been established in Western countries and in Taiwan. However, data from the Taiwan Society of Cardiology-Heart Failure with reduced Ejection Fraction (TSOC-HFrEF) registry showed suboptimal prescription of guideline-recommended medications. We aimed to analyze the reason of non-prescription and clinical outcomes as a result of under-prescription of medications. A total of 1509 patients hospitalized for acute HFrEF were recruited in 21 hospitals in Taiwan by the end of October 2014. Prescribed guideline-recommended medications and other relevant clinical parameters were collected and analyzed at discharge and 1 year after index hospitalization. At discharge, 62% of patients were prescribed with either angiotensin-converting enzyme-inhibitors (ACEI) or angiotensin receptor blockers (ARB); 60% were prescribed with beta-blockers and 49% were prescribed with mineralocorticoid receptor antagonists (MRA). The proportions of patients at ≥50% of the target dose for ACEI/ARB, beta-blockers and MRA were 24.4%, 20.6%, 86.2%, respectively. At 1-year follow-up, dosages of ACEI/ARB and MRA were up-titrated in about one-fourth patients, and dosages of beta-blocker were up-titrated in about 40% patients. One-year mortality rate was lowest in patients who received at least 2 classes of guideline-recommended medications with ≥50% of the target dose, and highest in those who received 0 or 1 class of medications. The TSOC-HFrEF registry demonstrated the under-prescription of guideline-recommended medications and reluctance of physicians to up-titrate medications to target dose. Action plan needs be formulated in order to improve physician's adherence to HF guidelines.

Chang HY ，Wang CC ，Wei J ，Chang CY ，Chuang YC ，Huang CL ，Chong E ，Lin JL ，Mar GY ，Chan KC ，Kuo JY ，Wang JH ，Chen ZC ，Tseng WK ，Cherng WJ ，Yin WH ... -  《-》

Heart failure medications prescribed at discharge for patients with left ventricular assist devices.

Real-world use of traditional heart failure (HF) medications for patients with left ventricular assist devices (LVADs) is not well known. We conducted a retrospective, observational analysis of 1,887 advanced HF patients with and without LVADs from 32 LVAD hospitals participating in the Get With The Guidelines-Heart Failure registry from January 2009 to March 2015. We examined HF medication prescription at discharge, temporal trends, and predictors of prescription among patients with an in-hospital (n = 258) or prior (n = 171) LVAD implant, and those with advanced HF but no LVAD, as defined by a left ventricular ejection fraction ≤25% and in-hospital receipt of intravenous inotropes or vasopressin receptor antagonists (n = 1,458). For β-blocker and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB), discharge prescriptions were 58.9% and 53.5% for new LVAD patients, 53.8% and 42.9% for prior LVAD patients, and 73.4% and 63.2% for patients without LVAD support, respectively (both P < .0001). Aldosterone antagonist prescription quadrupled among LVAD patients during the study period (P < .0001), whereas ACEI/ARB use decreased nearly 20 percentage points (60.0% to 41.4%, P = .0003). In the multivariable analysis of LVAD patients, patient age was inversely associated with β-blocker, ACEI/ARB, and aldosterone antagonist prescription. Traditional HF therapies were moderately prescribed at discharge to patients with LVADs and were more frequently prescribed to patients with advanced HF without LVAD support. Moderate prescription rates suggest clinical uncertainty in the use of antiadrenergic medication in this population. Further research is needed on the optimal medical regimen for patients with LVADs.

Shreibati JB ，Sheng S ，Fonarow GC ，DeVore AD ，Yancy CW ，Bhatt DL ，Schulte P ，Peterson ED ，Hernandez A ，Heidenreich PA ... -  《-》