JAHA: Multiple evidence-based therapies may be best recipe for HF patients

Employing guideline-recommended therapies in heart failure (HF) patients extends survival; however, benefits seem to plateau after any four to five therapies are used, according to results of a study published in the Feb. 22 issue of the online, open-access Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease (JAHA).

“Several therapies are guideline-recommended to reduce mortality in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF), but the incremental clinical effectiveness of these therapies has not been well studied. We aimed to evaluate the individual and incremental benefits for guideline-recommended HF therapies associated with 24-month survival,” according to background information from the article.

Because the value of these guideline-recommended therapies remains understudied, Gregg C. Fonarow, MD, of the Ronald Reagan-UCLA Medical Center, Los Angeles, and colleagues performed a case-control study of HF patients who were enrolled in the IMPROVE HF study to better understand the trends. The researchers identified 1,376 cases where patients died within 24 months and 2,752 cases where patients survived to 24 months (control arm). The mortality risk from incomplete application of evidence-based therapies among patients was calculated during the study.

During the study, researchers elevated seven guideline-recommended therapies for HF, including:

• ACE inhibitor or ARBs;

• Beta-blockers;
• Aldosterone antagonists;
• Anticoagulation for atrial fibrillation (AF)/flutter;
• Cardiac resynchronization therapy (CRT) with pacemaker or defibrillator;
• Implantable cardioverter-defibrillators (ICDs or CRT with defibrillator); and
• Patient education about HF.

According to the researchers, baseline treatment rates were higher among control patients who were eligible to receive ACE inhibitors/ARBs, beta-blockers, anticoagulation therapy for AF, ICD, CRT and HF education compared with most case subjects. However, there were no differences in terms of patients eligible to receive aldosterone antagonists.

“After adjustment for patient and practice characteristics, all guideline-recommended therapies except aldosterone antagonists were shown to be independently associated with a lower odds of death at 24 months,” the authors wrote.

The authors noted that beta-blocker usage and CRT was associated with the greatest reductions in the odds of death, 58 percent and 56 percent, respectively. ACE inhibitors/ARBs, ICDs, HF education and anticoagulation for AF were independently associated with lower adjusted odds of death.

Patients who receive a greater number of guideline-recommended therapies were more likely to survive at 24 months, the study summed. However, that benefit seemed to plateau after four to five therapies.

“Sequential application of specific therapies, in order of greatest to least individual associated benefit (beta-blocker, ACEI/ARB, ICD, HF education and anticoagulation for atrial fibrillation), yielded the lowest odds of death at 24 months,” the authors wrote.

Treating patients with the aforementioned five therapies, when compared with no treatment, was associated with an 83 percent reduction in the odds of experiencing death within 24 months.

While all of the seven guideline-recommended therapies decreased 24-month mortality, beta-blocker and CRT therapy had the greatest effect. “In addition, there was incremental benefit with each successive guideline-recommended therapy,” the authors wrote.

To further enhance the use of these guideline practices in clinical practice, the researchers suggested use of disease management systems and health IT.