Optimal Implementation of Evidence-Based HF Therapies and Mortality
Optimal Implementation of Evidence-Based HF Therapies and Mortality
Background Although multiple therapies have been shown to lower mortality in patients with heart failure (HF) and reduced left ventricular ejection fraction, their application in clinical practice has been less than ideal. To date, empiric estimation of the potential benefits that could be gained from eliminating these existing treatment gaps with optimal implementation has not been quantified.
Methods Eligibility criteria for each evidence-based HF therapy, the estimated frequency of use/nonuse of specific treatments, the case fatality rates, and the risk reductions due to treatment were obtained from published sources. The numbers of deaths prevented or postponed because of each guideline-recommended therapy and overall were determined.
Results Among patients with HF with reduced left ventricular ejection fraction in the United States (n = 2,644,800), the number eligible but not currently treated ranged from 139,749 for hydralazine/isorbide dinitrate to 852,512 for implantable cardioverter defibrillators. The comparative number of deaths that could potentially be prevented per year with optimal implementation of angiotensin-converting enzyme inhibitor/angiotensin receptor antagonist is 6,516; β-blockers, 12,922; aldosterone antagonists, 21,407; hydralazine/isorbide dinitrate, 6,655; cardiac resynchronization therapy, 8,317; and implantable cardioverter defibrillators, 12,179. If these treatment benefits were additive, optimal implementation of all 6 therapies could potentially prevent 67,996 deaths a year.
Conclusions A substantial number of HF deaths in this country could potentially be prevented by optimal implementation of evidence-based therapies. These data may underscore the importance of performance improvement efforts to translate evidence-based therapy to routine clinical practice so as to reduce contemporary HF mortality.
Heart failure (HF) is a substantial cause of mortality, morbidity, and health care expenditures in the United States. Randomized clinical trials have established the efficacy of certain therapies to reduce all-cause mortality for patients with HF and reduced left ventricular ejection fraction (LVEF). Based on the strength, depth, and breadth of the evidence, professional society guidelines have provided class I (useful/effective and the benefits outweigh the risks) recommendations for these select HF treatments including angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), β-blockers, aldosterone antagonists, hydralazine/isosorbide dinitrate, implantable cardioveter defibrillators (ICD), and cardiac resynchronization therapy (CRT). Despite this evidence, the adoption and application of these therapies in routine clinical care are slow and inconsistent. Although there may be multiple reasons for this, including clinical inertia, explicitly understanding the potential benefits of more consistent use of these treatments in routine clinical care can provide a strong motivation to improve the translation of evidence into practice.
To date, the potential magnitude of benefits of optimal implementation of evidence-based therapies in preventing or postponing deaths in patients with HF has not been quantified. Determining the respective gains that optimal application of each evidence-based therapy may provide is essential in prioritizing performance improvement efforts and planning future strategies. The aims of this study were to (1) quantify the current treatment gaps for each of the evidence-based therapies for HF with reduced LVEF and (2) quantify the projected gains for deaths prevented or postponed with optimal implementation of each of the evidence-based HF therapies and overall.
Abstract and Introduction
Abstract
Background Although multiple therapies have been shown to lower mortality in patients with heart failure (HF) and reduced left ventricular ejection fraction, their application in clinical practice has been less than ideal. To date, empiric estimation of the potential benefits that could be gained from eliminating these existing treatment gaps with optimal implementation has not been quantified.
Methods Eligibility criteria for each evidence-based HF therapy, the estimated frequency of use/nonuse of specific treatments, the case fatality rates, and the risk reductions due to treatment were obtained from published sources. The numbers of deaths prevented or postponed because of each guideline-recommended therapy and overall were determined.
Results Among patients with HF with reduced left ventricular ejection fraction in the United States (n = 2,644,800), the number eligible but not currently treated ranged from 139,749 for hydralazine/isorbide dinitrate to 852,512 for implantable cardioverter defibrillators. The comparative number of deaths that could potentially be prevented per year with optimal implementation of angiotensin-converting enzyme inhibitor/angiotensin receptor antagonist is 6,516; β-blockers, 12,922; aldosterone antagonists, 21,407; hydralazine/isorbide dinitrate, 6,655; cardiac resynchronization therapy, 8,317; and implantable cardioverter defibrillators, 12,179. If these treatment benefits were additive, optimal implementation of all 6 therapies could potentially prevent 67,996 deaths a year.
Conclusions A substantial number of HF deaths in this country could potentially be prevented by optimal implementation of evidence-based therapies. These data may underscore the importance of performance improvement efforts to translate evidence-based therapy to routine clinical practice so as to reduce contemporary HF mortality.
Introduction
Heart failure (HF) is a substantial cause of mortality, morbidity, and health care expenditures in the United States. Randomized clinical trials have established the efficacy of certain therapies to reduce all-cause mortality for patients with HF and reduced left ventricular ejection fraction (LVEF). Based on the strength, depth, and breadth of the evidence, professional society guidelines have provided class I (useful/effective and the benefits outweigh the risks) recommendations for these select HF treatments including angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), β-blockers, aldosterone antagonists, hydralazine/isosorbide dinitrate, implantable cardioveter defibrillators (ICD), and cardiac resynchronization therapy (CRT). Despite this evidence, the adoption and application of these therapies in routine clinical care are slow and inconsistent. Although there may be multiple reasons for this, including clinical inertia, explicitly understanding the potential benefits of more consistent use of these treatments in routine clinical care can provide a strong motivation to improve the translation of evidence into practice.
To date, the potential magnitude of benefits of optimal implementation of evidence-based therapies in preventing or postponing deaths in patients with HF has not been quantified. Determining the respective gains that optimal application of each evidence-based therapy may provide is essential in prioritizing performance improvement efforts and planning future strategies. The aims of this study were to (1) quantify the current treatment gaps for each of the evidence-based therapies for HF with reduced LVEF and (2) quantify the projected gains for deaths prevented or postponed with optimal implementation of each of the evidence-based HF therapies and overall.