Up to 80 percent of heart failure patients denied therapy to reduce hospitalization and early death

"One in five people will develop heart failure over their lifetime and 15 million people currently suffer from heart failure in Europe," said lead author Dr Pardeep Jhund, a cardiologist at the University of Glasgow, Scotland, UK. "Patients are frequently admitted to hospital and are at a high risk of dying. Effective, recommended therapies exist, but are potentially being under-used in clinical practice."

"Therefore, we wanted to understand whether patients with heart failure are receiving the best treatment available to them," he continued.

European Society of Cardiology heart failure guidelines outline the type and dose of therapy that patients with the most common type of heart failure should receive (called heart failure with reduced ejection fraction, or HFrEF). This study examined whether patients with heart failure in the UK actually receive these treatments.

This two-year, retrospective, observational study examined the primary care records of 14,546 heart failure patients included in the UK Clinical Practice Research Datalink (CPRD), a large database used by general practitioners in the UK. The investigators assessed rates and causes of hospitalisation, rates of serious illnesses and deaths, and treatment practices from 2009 to 2011.

The analysis only included records of patients who had been receiving treatment for at least one year and who could be followed up for one additional year. Information on the type and dose of treatment was recorded and compared with those recommended in the heart failure guidelines. Patients were considered to be receiving a recommended dose of a therapy if their prescribed dose was within 25% of the recommended target dose.

The key finding was that a large proportion of patients were not receiving guideline-recommended treatments. Guidelines recommend that HFrEF patients receive an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB). This should be combined with a beta-blocker, and, in a large number of patients, a mineralocorticoid receptor antagonist (MRA) should be added. In this study, 80% of patients were receiving an ACE inhibitor or ARB; but only 57% were prescribed a beta-blocker and 31% were given a MRA.

Furthermore, only 35% of patients receiving an ACE inhibitor or ARB and 20% of those receiving a beta-blocker were on the recommended target doses. Of those receiving a MRA, 78% were on the target dose. This highlights that up to 80% of eligible patients with heart failure may not be receiving treatment at doses that have been proven to reduce hospitalisations and improve survival.

Rates of serious illnesses and death were high. In this elderly population (average age: 79 years), 26-50% had a history of serious health conditions, such as atrial fibrillation, coronary heart disease, type 2 diabetes or chronic kidney disease. Patients were frequently hospitalised and stayed in hospital for up to 15 days. Each year, 14% of patients died and half of the deaths were due to cardiovascular disease.

Dr Jhund said: "These findings emphasise the need to treat patients with heart failure using evidence-based, recommended therapies at doses that have been shown to be effective in clinical trials. This is vitally important considering the high costs of hospitalisation and poor life expectancy associated with this condition."

Dr Jhund concluded: "Our results highlight that rates of hospital admissions and deaths in patients with heart failure remain substantial. Evidence-based, guideline-recommended therapies are under-used, and used at lower doses than those shown to be effective. Prescription rates of therapies must increase, and therapies must be prescribed at higher doses, to reduce hospitalisations and help these patients live longer."