title: Comparison of medical therapy dosing in outpatients cared for in cardiology practices with heart failure and reduced ejection fraction with and without device therapy: report from IMPROVE HF.
abstract: BACKGROUND
  Few data exist to characterize the delivery of evidence-based medical therapy for outpatients with heart failure who have received implantable cardioverter-defibrillators or cardiac resynchronization therapy (CRT) for systolic dysfunction.
  
  
  RESULTS
  IMPROVE HF is a prospective study characterizing the management of 15 381 outpatients with systolic heart failure (left ventricular ejection fraction ≤35%) enrolled from 167 US cardiology practices. Data were abstracted for dose, type, and daily frequency for angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, and aldosterone antagonists. Target doses for each medication class were based on current guidelines. Patients with devices (implantable cardioverter-defibrillators, CRT with defibrillators, or CRT with pacemakers) more frequently received evidence-based medical therapy than did those without such devices, although treatment at or above target doses was low for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (implantable cardioverter-defibrillators 32.6%, CRT with pacemaker 30.7%, CRT with defibrillator 32.0%, no device 34.6%) and β-blockers (20.2%, 17.4%, 20.4%, and 15.3%, respectively). Fewer patients received aldosterone antagonists, although when used, doses were more frequently within the target dosing range (70.1%, 72.1%, 72.7%, and 76.5%, respectively). Multivariable models showed that use of CRT with defibrillators and CRT with pacemakers was significantly associated with delivery of β-blockers at or above target doses, but no device therapies were associated with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker or aldosterone antagonist dosing.
  
  
  CONCLUSIONS
  Patients treated with heart failure devices received evidence-based medical therapy at similar or greater frequency than did those without such devices. Patients with CRT with defibrillator or CRT with pacemaker devices were more likely to be treated with target doses of β-blockers than were patients not treated with device therapy. Doses of evidenced-based therapies remain significantly lower in clinical practice than in clinical trials.
  
  
  BACKGROUND
  URL: http://www.clinicaltrials.gov. Unique identifier: NCT00303979.
authors.affiliation: Division of Cardiology, Scripps Clinic Torrey Pines, La Jolla, Calif 92037, USA. Heywood.Tom@scrippshealth.org
authors.forename: J Thomas
authors.initials: JT
authors.lastname: Heywood
authors.forename: Gregg C
authors.initials: GC
authors.lastname: Fonarow
authors.forename: Clyde W
authors.initials: CW
authors.lastname: Yancy
authors.forename: Nancy M
authors.initials: NM
authors.lastname: Albert
authors.forename: Anne B
authors.initials: AB
authors.lastname: Curtis
authors.forename: Mihai
authors.initials: M
authors.lastname: Gheorghiade
authors.forename: Patches Johnson
authors.initials: PJ
authors.lastname: Inge
authors.forename: Mark L
authors.initials: ML
authors.lastname: McBride
authors.forename: Mandeep R
authors.initials: MR
authors.lastname: Mehra
authors.forename: Christopher M
authors.initials: CM
authors.lastname: O'Connor
authors.forename: Dwight
authors.initials: D
authors.lastname: Reynolds
authors.forename: Mary Norine
authors.initials: MN
authors.lastname: Walsh
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage*; D000368:Aged; D000553:Ambulatory Care / Q000379:methods*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage*; D002304:Cardiac Pacing, Artificial; D017147:Defibrillators, Implantable; D019317:Evidence-Based Medicine; D005260:Female; D006333:Heart Failure / Q000188:drug therapy*; D006801:Humans; D008297:Male; D000451:Mineralocorticoid Receptor Antagonists / Q000008:administration & dosage*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012042:Registries; D012044:Regression Analysis; D018709:Statistics, Nonparametric; D013318:Stroke Volume; D016896:Treatment Outcome; D014481:United States
chemical_list: D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000451:Mineralocorticoid Receptor Antagonists