Background According to current clinical guidelines developed from evidence-based medicine, heart failure with ventricular dysfunction needs to be treated with the combination of an ACE inhibitor and a beta blocker. An aldosterone antagonist should be added in the more advanced stages of heart failure or recent myocardial infarction.
Purpose To review the treatment of patients diagnosed with heart failure in order to evaluate whether they were properly treated according to current clinical guidelines.
Materials and methods In 2012 we conducted a retrospective review of the medical records of all patients admitted to the Internal Medicine Service of a second level hospital with a discharge diagnosis (principal diagnosis or comorbidity) of heart failure. 100 paper medical charts were randomly selected from a total of 521 found and clinical, laboratory and echocardiographic data and patient’s medicines at discharge were collected and analysed using the SPSS statistical package.
Results With regard to cardiovascular drugs, discharge treatment included diuretics (85%), ACE inhibitors (42%), statins (39%), digoxin (35%), ARBs (30%), calcium antagonists (24%) and beta blockers (24%). Unfortunately no distinction was made in the data collection between different types of diuretics, so analysis of aldosterone antagonist therapy was missed. 65% of the patients had heart failure with systolic dysfunction, of which 68% were female and had a mean age of 74.6 years. The primary reasons for admission were: respiratory infection (31%), cardiac arrhythmia (28%) and cardiac ischemia (20%). Comorbidities associated with heart failure were hypertension (70%), diabetes mellitus (52%), atrial fibrillation (33%), COPD (15%) and chronic renal failure (10%). 28% of patients didn’t received any drug blocking the renin angiotensin system, and an even higher percentage, 76%, no beta blocker, although both groups of drugs are well known for improving survival. Of those patients prescribed an ARB antagonist or an ACE inhibitor, a higher percentage of patients received an ARB inhibitor (42%) than was felt justified.
Conclusions The data indicate that, according to current recommendations, a significant percentage of patients are undertreated. The high percentage of patients prescribed diuretics suggests the focus is on symptom relief, rather than on prognosis. These findings are consistent with the literature and indicate that there are legitimate reasons for undertreatment by general physicians, such as the concern of adding a hypotensive drug or a potentially nephrotoxic drug in elderly patients with multiple significant comorbidities. A specialist heart failure team in our area would benefit patients by minimising unnecessary drugs (including diuretics) and initiating and uptitrating ACE inhibitors and beta blockers in these patients.
No conflict of interest.
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