1. Clinical Impact of Adherence to Pharmacotherapeutic Guidelines on the Outcome in Patients with Chronic Heart Failure Suntheep Batra, M.Pharm Department of Pharmaceutical Care Faculty of Pharmacy, Payap University Chiang Mai, Thailand

2. Background ACEIs, ARBs, AAs and BBs have been shown to improve hospitalization and survival, and were recommended in several CHF guidelines However, many patients still received suboptimal prescription of recommended medications The impact of guidelines adherence on clinical outcomes in CHF patients has never been evaluated in Thailand

3. Objectives To evaluate guidelines adherence in CHF patients To investigate the impact of adherence to CHF guidelines on the rate of cardiac events (composite endpoint of CHF hospitalization or cardiovascular death)

4. Methods Study design  Retrospective cohort observational study Patients  331 patients who were admitted to Nakornping Hospital between October 2005 and December 2007 for HF exacerbation were enrolled and followed-up until June 30, 2009

5. Methods (Cont’) Assessment of Guidelines Adherence  Guideline adherence indicator (GAI-3) were calculated after hospital discharge for at least 3 months based on recommendation of ACC/AHA 2005, ESC 2005, and HAT 2008 guidelines  Patients were categorized to three adherence groups according to GAI-3  Low adherence: 0-33%  Medium adherence: 50-66%  High adherence: 100%

6. Methods (Cont’) Assessment of Guidelines Adherence (Cont’)  Calculation of GAI-3 ACEIs/ARBs Beta-blockers Aldosterone- antagonists Aldosterone- antagonists GAI-3 (%) NYHA II NYHA III/IV YES - - 2×50 YES 3×33.3 Low adherence: GAI-3 = 0-33% Medium adherence: GAI-3 = 50-67% High adherence: GAI-3 = 100%

7. Results Adherence rates of recommended drug regimens Medications Prescribed according to the guideline (%) ACEIs67.5 ARBs100.0 ACEIs/ARBs71.6 Beta-blockers41.8 ACEIs/ARBs + Beta-blockers28.8 Aldosterone antagonists76.4 Diuretics100.0 Cardiac glycosides89.0

8. Results (Cont’) Cardiac events among 3 adherence groups Patient groupsn GAI3 (%) (Median, IQR) Cardiac events rate (/100 person-years) Median survival time (month) (95%CI) P- value * Low adherence (GAI3 = 0-33%) 115 50.0 (0.0- 100.0) 97.14.9 (3.7-6.1) 0.004 Medium adherence (GAI3 = 50-67%) 12967.510.6 (6.9-14.4) High adherence (GAI3 = 100%) 8747.420.3 (16.5-24.0) *Log-rank test was used to test differences between the three adherence groups

9. Results (Cont’) Multivariate predictors of cardiac events Predictors * N Multivariate analysis HR95%CIP-value † GAI3 score Low (0-33%) Medium (50-66%) High (100%) 115 129 87 1 0.21 0.16 0.10-0.44 0.03-0.97 <0.001 0.047 *Adjusted with age, NYHA class, hypertension, coronary heart disease, chronic kidney disease, diabetes mellitus, prescription of recommended drugs and dosage of ACEIs/ARBs and beta-blockers †Cox-proportional hazards regression analysis

10. Results (Cont’) Kaplan–Meier curve for multivariate analysis High GAI-3 Medium GAI-3 Low GAI-3

11. Conclusion Adherence to pharmacotherapeutic guidelines for CHF was a significant predictor of fewer cardiac events in clinical practice in Thailand