doi: 10.1161/CIRCULATIONAHA.107.719492
(Circulation. 2007;116:693-695.)
© 2007 American Heart Association, Inc.
Editorial |
Patients’ Persistence of Evidence-Based Treatment of Chronic Heart Failure
A Treatment Paradox
From the Institute of Health and Care Sciences (I.E.) and the Department of Emergency and Cardiovascular Medicine (K.S.), Sahlgrenska Academy, Göteborg University, Göteborg, Sweden.
Correspondence to Dr Karl Swedberg, Department of Medicine, Sahlgrenska University Hospital/Östra, 416 85 Göteborg, Sweden. E-mail karl.swedberg{at}gu.se
Key Words: Editorials • Heart Failure • Morbidity • Mortality
Chronic heart failure (CHF) is associated with high morbidity, mortality, disability, and reduced quality of life.1 These problems linked to CHF are still valid despite dramatic beneficial improvements in treatment in the past 10 to 15 years. Treatment of CHF includes not only pharmacological options but also various devices for patients with more pronounced symptoms and/or myocardial systolic dysfunction. In the major Guidelines on Treatment of Chronic Heart Failure it is stated that optimal treatment requires a combination of neurohormonal agents.2 Accordingly, even if the benefits of treatment have improved, the management mode of these therapies has become increasingly more complicated. In cross-sectional studies, it has been reported that treatments are underused, both with regard to agents and dose levels.3 It has been suggested that the reasons for this situation are the complexity of the combination of agents and the hesitancy of the treating physician or the patient. An understanding of how treatments are prescribed, delivered, and comprehended by the patient is important if prognosis is to be further improved.
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The beneficial effect of the recommended pharmacological approach to treatment of patients with CHF is now even reflected in population registries with decreasing mortality.4 It is therefore obvious that neglect or underuse of these treatments is not good medical practice, and there should be a mandate for everyone who cares for patients with heart failure to tailor optimal treatment to each patient. An important barrier to success in this process is when patients are discharged from hospital and the subsequent optimization of treatment.
In this issue of Circulation, Gislason and colleagues have studied this problem more carefully in a large data set from the Danish National Patient Registry.5 An important limitation in their study is that the degree of left ventricular dysfunction is not documented. However, on the basis of another large data set from a screening study in Denmark, they are able to estimate the proportion of patients with systolic dysfunction to 
60% and patients eligible for β-blockade to 50%.6 There are several important findings that have a clear impact on clinical practice as pointed out by the authors. First, the dose and the combination of neurohormonal agents at discharge from hospital set the platform for future treatment. There was a relatively limited subsequent uptitration of these agents after 90 days. The exception was carvedilol, in which higher dose levels were reached. The average dose levels seem to be 50% of the recommended target dose level. This figure is comparable with those found in other surveys.3 One piece of information of interest is the increased use of β-blockers where the prescriptions doubled from 1997 to 2004, and a high proportion of eligible patients (80%) received such an agent. β-Blocker therapy is the best documented and most effective treatment of CHF.7
Another bit of new information of importance is that patients who persisted with prescribed treatment showed better subsequent survival than those who withdrew even after long-term therapy. Furthermore, patients who were treated with several neurohormonal blockers seemed to adhere better to the medication on a long-term basis. This type of information has previously not been available from a large registry such as this.
Adherence to medical therapy in CHF is important. We were able to demonstrate this fact in an analysis of the Candesartan in Heart failure: Assessment of Mortality and morbidity (CHARM) program, in which patients who adhered (even to placebo) had significantly better survival.8 Adherence to a medication regimen is generally defined as the extent to which patients take medications as prescribed by their healthcare provider. Nonadherence is often defined in clinical trials when <80% of the medicines are taken as prescribed. Nonadherers are high-risk patients and consequently require special attention. Factors that are associated with improved adherence are difficult to define as well as what structure of follow-up can improve this important element of the follow-up program. Discharge planning should therefore include careful identification of each patient’s perception of their condition and treatment.
The implication of the findings from the study of Gislason and coworkers could be that a defined and structured approach to postdischarge management is important as long-term treatment with life-saving agents is defined early. Such an approach might also improve optimal dose levels and combinations of neurohormonal blockers. Discharge planning and follow-up in primary care or heart failure clinics may present opportunities to encourage patients’ familiarity with medication. Paradoxically, when general practitioners are interviewed in primary care about treatment strategies in patients with CHF, Fuat and coworkers9 found that, although they appreciated the benefits of modern treatment shown in large scale trials, a minority of general practitioners were reluctant to use them, especially in elderly patients. This reluctance was related to fears about side effects, especially hypotension and collapse in the community setting, as well as the lack of monitoring guidelines in the context of primary care. In particular, polypharmacy was viewed negatively, which is an intriguing observation in light of the finding by Gislason et al that an increased number of concomitant medications were associated with high persistence of treatment. If lay persons were aware of the benefit of optimized evidence-based medication, they would probably demand this treatment on behalf of themselves or their relatives. Unfortunately, studies indicate that awareness of the purpose and benefit of medication is low in the majority of patients with CHF in the sense that patients rely on their health providers and "do as they are told".10 This obedience or compliance seems to be reflected in the paper by Gislason et al as a high degree of persistence (defined as subsequent prescription claims). Findings from the Improvement Programme in Evaluation and Management (IMPROVEMENT) survey, however, showed that primary care physicians prescribe evidence-based treatment less and in lower doses than recommended by the guidelines.11 Gislason et al found that early initiation of treatment led to subsequent high persistence of treatment once medication was started, but treatment dosages were below recommended dosages. Perhaps patients need to be more "disobedient" in terms of not just doing what they are told but being more demanding and asking their health provider not only to subscribe the best treatment for them but also asking for optimal doses.
Specialist nurses in primary care and heart failure clinics may offer opportunities to guide patients through treatment plans and thus help make them aware of recommended dose levels. Similarly, better labeling of drugs and written instructions on their purpose and use are simple methods to increase patients’ involvement in treatment and therefore should not be overlooked.
Because patients with CHF want to participate actively in discussions about their care and treatment, it is extremely important that health professionals encourage such participation12. Although we have recently shown that highly adherent patients have better clinical outcomes, pedagogical strategies to obtain good information about medicines remain a challenge.8 In addition to pedagogical and didactical skills, good pharmacological knowledge provides a strong basis for communication between the health provider and patient. Team approaches that involve nurses and pharmacists in the follow-up of patients with CHF in their homes after discharge have been found to optimize treatment.13 Of utmost importance in follow-up after hospitalization is to obtain the patients’ perspective on their present condition and medicines. This is easily achieved by simply asking the patients about their thoughts and ideas of the prescribed treatment. Assessments made by care providers of the patients’ need for information may sometimes not be well grounded in the patients’ own perceptions. We have found that patients with CHF reported that they needed significantly more information about medicines than nurses were aware of14. As noted by Riegel and coworkers,15 one aspect of the problem may be a preference by nurses to discuss nonpharmacological treatment (even if several of those were not evidence-based). Only 23% of interviewed nurses considered information about medicines to be the most important topic for patient education. In several studies, patients have reported that the information from caregivers focused on side effects rather than expectations that surround both long- and short-term symptom relief as well as longer life.16,17 Facilitation of a more active patient role is consistent with guidelines and is crucial for long-term quality care to succeed.18
In summary, health professionals have a major challenge to provide optimal life-prolonging treatments in patients with CHF. It is now demonstrated that patients with complicated medications can adhere to these medications, which will improve survival, and it is the healthcare providers that need to provide these beneficial treatments. The methods to achieve optimal treatment and care need the attention of not only the physicians and nurses but also of the patients and their relatives.
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Acknowledgments |
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Disclosures
None.
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Footnotes |
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The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
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References |
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 Top References |
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