Treatment and Risk in Heart Failure: Gaps in Evidence or Quality? Pamela N. Peterson, MD MSPH; John S. Rumsfeld, MD PhD; Li Liang PhD; Adrian F. Hernandez, MD MHS; Eric D. Peterson, MD MPH; Gregg C. Fonarow, MD; Frederick A Masoudi, MD MSPH

Background ACE-Inhibitors or angiotensin receptor blockers (ARBs) and beta blockers reduce morbidity and mortality in patients with heart failure (HF) and left ventricular systolic dysfunction (LVSD). The use of evidence-based therapies such as ACE-Inhibitors, ARBs and beta blockers with HF and LVSD is significantly lower in patients with increased risk. In order to optimize the use of evidence based therapies and improve HF outcomes, more data is needed to assess how to safely treat high risk patients with contraindications. Peterson PN, et al. CIRCULATIONAHA/2009/879478

Introduction Peterson, PN, et al. CIRCULATIONAHA/2009/ Clinical practice guidelines recommend that certain evidence- based therapies are given to patients with HF and LVSD who do not have a contraindication to that therapy. Research has shown that high risk patients are less likely to receive these evidence-based therapies.

Objective Using the data from the GWTG-HF database from GWTG- HF participating hospitals, the purpose of the paper was to evaluate whether high risk patients who do not receive evidence based therapies is due to contraindications or contributed to gaps in the quality of care. Peterson, PN. et al. CIRCULATIONAHA/2009/879478

Methods Data were collected from 18,307 patients with left systolic dysfunction surviving hospitalization between January 2005 and June 2007, from 194 GWTG-HF participating hospitals. The GWTG-HF risk prediction score was used to categorize patients according to their estimated in-hospital mortality risk. The proportion of patients with documented contraindications and without contraindications to ACE-inhibitors or ARBs and beta blockers at hospital discharge was determined across all levels of risks. This included worsening renal function and symptomatic hypotension, median discharge serum creatinine and mean discharge blood pressure. Peterson, PN. et al. CIRCULATIONAHA/2009/879478

Results 13% of the patient population had a documented contraindication to ACE/ARBs and 7% to beta blockers. Although the proportion of patients with documented contraindications increased significantly with increasing risk, 67% of patients in the highest risk group were still eligible for both therapies. The proportions of patients without a documented contraindication received a discharge prescription for ACE-Inhibitors and ARBs was 84.9% and for beta blockers were 89.7%. As mortality risk increased, the proportions of patients eligible for therapy who were treated at discharge decreased for both ACE/ARBs (p<0.001) and beta blockers (<0.001). Peterson PN. et al. CIRCULATIONAHA/2009/879478

Conclusions The rates of use of guideline-based therapies in patients with HF and LVSD were significantly lower as patient risk increased due to high rates of contraindications to evidence- based therapies and low rates of use among eligible patients. The development of additional strategies is needed to assure that eligible high-risk patients can safely receive evidence- based therapies. More broad evidence based strategies are warranted for while those who are not eligible for guideline-based therapies. Peterson, PN. et al. CIRCULATIONAHA/2009/879478