title: Temporal improvement in heart failure survival related to the use of a nurse-directed clinic and recommended pharmacological treatment.
abstract: BACKGROUND
  The use of recommended drugs for chronic heart failure (CHF) has been discouragingly low in clinical practice. The aim of this study was to prospectively evaluate to which extent a nurse-directed heart failure clinic could accomplish drug titration with modern heart failure treatments, with focus on beta-blockers.
  
  
  METHODS
  Outcome of drug titration was evaluated for 418 patients referred to the nurse-run clinic from 1995 through 2001, using a prospective, open, non-randomised quality control protocol.
  
  
  RESULTS
  Throughout the period, most of the patients were discharged on an ACE inhibitor (during 2001, 86%). The use of beta-blockers increased during the observation (from 43% to 88%). Patients started on an ACE-inhibitor treatment continued in 89% and in 95% when started on a beta-blocker. There was a significant decrease in mortality, relative risk per year 0.84 (95% CI, 0.75 to 0.94), P=0.002. Three-year mortality was reduced from 27% to 10%. In a multivariable analysis, survival was significantly associated with ejection fraction, renal function, the use of beta-blockers and ACE inhibitors, and negatively with digitalis treatment.
  
  
  CONCLUSIONS
  The nurse-directed titration succeeded in introducing more patients on beta-blockers than on ACE-inhibitors. Mortality was reduced during the study period, associated with more use of documented therapy, beta-blockers in particular. These findings suggest that the observed signs of improvement in CHF prognosis are likely caused by more efficient medical treatment.
authors.affiliation: Department of Cardiology, Sahlgrenska University Hospital, SE 413 45 Göteborg, Sweden. bert.andersson@wlab.gu.se
authors.forename: Bert
authors.initials: B
authors.lastname: Andersson
authors.forename: Ewa
authors.initials: E
authors.lastname: Kjörk
authors.forename: Gertrud
authors.initials: G
authors.lastname: Brunlöf
mesh_terms: D000293:Adolescent; D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence / Q000592:standards; D006333:Heart Failure / Q000188:drug therapy* / Q000401:mortality* / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009720:Nurse Clinicians / Q000592:standards; D009723:Nurse-Patient Relations; D010044:Outpatient Clinics, Hospital / Q000592:standards; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D013318:Stroke Volume / Q000187:drug effects; D016019:Survival Analysis; D017186:Titrimetry; D016896:Treatment Outcome
chemical_list: D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors