The Year in Cardiology

Heart Failure: the Year in Cardiology 2019

John G.F. Cleland; Alexander R. Lyon; Theresa McDonagh; John J.V. McMurray

Disclosures

Eur Heart J. 2020;41(12):1232-1248. 

In This Article

Implementation of Therapy

Analyses of administrative data from primary care in the UK suggest that implementation of therapy has improved substantially over the last decade, with 72% now prescribed a beta-blocker, although many patients remain on less than target doses.[6] Amongst hospital discharges in England and Wales, 89% of those with HFrEF were discharged on a beta-blocker (https://www.nicor.org.uk/wp-content/uploads/2019/09/Heart-Failure-2019-Report-final.pdf), which is very similar to that observed in patients with HFrEF selected for enrolment in the ESC-EURObservational Heart Failure Long-Term Registry.[137] However, an analysis of Medicare beneficiaries in the USA found that only 51% of patients with HFrEF were prescribed a beta-blocker after a first or recurrent hospitalization for heart failure and only 12% received at least ≥50% of the target dose by 1 year.[138] This suggests that the organization of care for HFrEF makes an important difference to treatment and, consequently, outcome. However, a cluster RCT (n = 2494) of service redesign aiming to improve hospital-to-home transition, which included self-care education, a structured hospital discharge summary, family physician follow-up within 1 week, and, for high-risk patients, home-visits, did not substantially improve patient well-being or outcome.[139] An RCT (n = 110) showed that frequent (several times per month) visits to participating community pharmacies could improve medication adherence and well-being.[140] An RCT of 450 patients found benefits of e-Health intervention on self-care behaviour and quality of life in the first 3 months after initiation but not thereafter,[141] with no effect on hospitalizations or mortality. There are many reasons why RCTs of complex interventions fail including inadequate power, suboptimal trial design, already excellent or unintended improvements in care for the control group, lack of long-term engagement and motivation of staff and patients, inclusion of patients for whom pharmacological intervention is largely ineffective (e.g. HFpEF) but sometimes we just have to admit that what should work does not. More evidence is required; learning from past experience.[142]

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