PMID- 32800509 OWN - NLM STAT- MEDLINE DCOM- 20210830 LR - 20210830 IS - 2213-1787 (Electronic) IS - 2213-1779 (Linking) VI - 8 IP - 9 DP - 2020 Sep TI - Care Gaps in Adherence to Heart Failure Guidelines: Clinical Inertia or Physiological Limitations? PG - 725-738 LID - S2213-1779(20)30333-4 [pii] LID - 10.1016/j.jchf.2020.04.019 [doi] AB - OBJECTIVES: This study evaluated the impact of clinical and physiological factors limiting treatment optimization toward recommended medical therapy in heart failure (HF). BACKGROUND: Although guidelines aim to assist physicians in prescribing evidence-based therapies and to improve outcomes of patients with HF and reduced ejection fraction (HFrEF), gaps in clinical care persist. METHODS: Medical records of all patients with HFrEF followed for at least 6 months at the authors' HF clinic (n = 511) allowed for drug optimization and were reviewed regarding the prescription rates of recommended pharmacological agents and devices (implantable cardioverter-defibrillator [ICD] or cardiac resynchronization therapy [CRT]). Then, an algorithm integrating clinical (New York Heart Association [NYHA] functional class, heart rate, blood pressure and biologic parameters (creatinine, serum potassium) based on the inclusion/exclusion criteria of landmark trials guiding these recommendations) was applied for each agent and device to identify potential explanations for treatment gaps. RESULTS: Gross prescription rates were high for beta-blockers (98.6%), mineralocorticoid receptor antagonist (MRA) (93.4%), vasodilators (90.3%), ICDs (75.1%), and CRT (82.1%) among those eligible, except for ivabradine (46.3%, n = 41). However, achievement of target physiological doses was lower (beta-blockers, 67.5%; MRA, 58.9%; and vasodilators, 63.4%), and one-fifth of patient dosages were still being up-titrated. Suboptimal doses were associated with older age (odds ratio [OR]: 1.221; p < 0.0001) and history of stroke or transient ischemic attack (TIA) (no vs. yes, OR: 0.264; p = 0.0336). CONCLUSIONS: Gaps in adherence to guidelines exist in specialized HF setting and are mostly explained by limiting physiological factors rather than inertia. Older age and history of stroke/TIA, potential markers of frailty, are associated with suboptimal doses of guideline-directed medical therapy, suggesting that an individualized rather than a "one-size-fits-all" approach may be required. CI - Copyright (c) 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved. FAU - Jarjour, Marilyne AU - Jarjour M AD - Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada. FAU - Henri, Christine AU - Henri C AD - Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada. FAU - de Denus, Simon AU - de Denus S AD - Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada. FAU - Fortier, Annik AU - Fortier A AD - Biostatistics, Montreal Health Innovation Coordinating Center, Montreal, Quebec, Canada. FAU - Bouabdallaoui, Nadia AU - Bouabdallaoui N AD - Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada. FAU - Nigam, Anil AU - Nigam A AD - Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada. FAU - O'Meara, Eileen AU - O'Meara E AD - Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada. FAU - Ahnadi, Charaf AU - Ahnadi C AD - Collaborative Research for Effective Diagnostics, University Hospital Center of Sherbrooke, Sherbrooke, Quebec, Canada. FAU - White, Michel AU - White M AD - Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada. FAU - Garceau, Patrick AU - Garceau P AD - Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada. FAU - Racine, Normand AU - Racine N AD - Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada. FAU - Parent, Marie-Claude AU - Parent MC AD - Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada. FAU - Liszkowski, Mark AU - Liszkowski M AD - Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada. FAU - Giraldeau, Genevieve AU - Giraldeau G AD - Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada. FAU - Rouleau, Jean-Lucien AU - Rouleau JL AD - Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada. FAU - Ducharme, Anique AU - Ducharme A AD - Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada. Electronic address: anique.ducharme@umontreal.ca. LA - eng PT - Journal Article PT - Research Support, Non-U.S. Gov't DEP - 20200812 PL - United States TA - JACC Heart Fail JT - JACC. Heart failure JID - 101598241 RN - 0 (Mineralocorticoid Receptor Antagonists) SB - IM CIN - JACC Heart Fail. 2020 Sep;8(9):739-741. PMID: 32800507 MH - Aged MH - *Cardiac Resynchronization Therapy MH - *Defibrillators, Implantable MH - *Heart Failure/therapy MH - Humans MH - Mineralocorticoid Receptor Antagonists MH - *Patient Compliance MH - Registries MH - Stroke Volume OTO - NOTNLM OT - adherence OT - guidelines OT - heart failure OT - inertia OT - pharmacological therapy EDAT- 2020/08/18 06:00 MHDA- 2021/08/31 06:00 CRDT- 2020/08/18 06:00 PHST- 2019/11/19 00:00 [received] PHST- 2020/04/13 00:00 [revised] PHST- 2020/04/30 00:00 [accepted] PHST- 2020/08/18 06:00 [pubmed] PHST- 2021/08/31 06:00 [medline] PHST- 2020/08/18 06:00 [entrez] AID - S2213-1779(20)30333-4 [pii] AID - 10.1016/j.jchf.2020.04.019 [doi] PST - ppublish SO - JACC Heart Fail. 2020 Sep;8(9):725-738. doi: 10.1016/j.jchf.2020.04.019. Epub 2020 Aug 12.