Guidelines for Choosing Drugs in Chronic Heart Failure

Guidelines for choosing drugs in chronic heart failure In a recent article, Komajda and colleagues (2005) presented data gathered from the Medical Management of Chronic Heart Failure in Europe and its Related Costs (MAHLER) survey in support of the view that adherence to guidelines in treating patients with chronic heart failure is a strong predictor of fewer cardiovascular hospitalizations in clinical practice. Five types of drugs were considered as the agents of choice in the treatment of chronic heart failure: angiotensin-converting enzyme (ACE) inhibitors, β-adrenoceptor antagonists (blockers), potassium sparing diuretic (spironolactone), cardiac glycosides, and diuretics other than the potassium-sparing class. The total number of patients included in the trial were 1421, of whom 1333 (93.8%) completed the study. Baseline medications in these patients were ACE inhibitors (69%), angiotensin type 1 receptor antagonists (17.6%), β-adrenoceptor antagonists (53%), diuretics (79%), cardiac glycosides (41%), and spironolactone (28%). Adherence was considered perfect if the first three (T3) drugs (ACE inhibitor, β-adrenoceptor antagonist, and spironolactone) were used, and this was compared with a situation when either the latter three were not used concomitantly or a condition in which all five (T5) were used as part of the regime to treat chronic heart failure. The overall guideline adherence indicators for T3 and T5 were 60% and 63%, respectively, with class adherence for ACE inhibitors (85.4%), diuretics (83%), β-adrenoceptor antagonists (58%), cardiac glycosides (52%), and spironolactone (36%) (Komajda et al 2005). Of particular interest, are two issues that are worth addressing based on the findings from the Komajda et al report. First, the data presented supports the view that β-adrenoceptor antagonists are underutilized in the treatment of patients with chronic heart failure. This is somewhat surprising as there is substantive evidence to indicate that this class of drugs should form an integral part of a strategy in treating patients with this condition. A previous survey on the quality of care among patients with heart failure in Europe had also revealed an underutilization of β-adrenoceptor antagonists in these patients (The Study Group of Diagnosis of the Working Group on Heart Failure of the European Society of Cardiology 2003). The evidence from this report seems to indicate that the rate of prescription for β-adrenoceptor antagonists was 36.9%, with metoprolol being the most widely used (40.3%) agent among the β-adrenoceptor antagonists. There is clear evidence from a number of clinical trials that indicate the benefits of β-adrenoceptor antagonists in patients …