Temporal improvement in heart failure survival related to the use of a nurse-directed clinic and recommended pharmacological treatment.
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.
Andersson
Bert
B
Department of Cardiology, Sahlgrenska University Hospital, SE 413 45 Göteborg, Sweden. bert.andersson@wlab.gu.se
Kjörk
Ewa
E
Brunlöf
Gertrud
G
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
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors