title: Is heart failure guideline adherence being underestimated? The impact of therapeutic contraindications.
abstract: BACKGROUND
  Several studies based on claims data have reported underutilization of evidence-based heart failure (HF) therapies. The degree to which these estimates fail to account for therapeutic contraindications is unclear.
  
  
  METHODS
  We identified patients with HF and left ventricular ejection fraction ≤45% seen between January 1, 2010, and July 1, 2010, at a tertiary care Veterans Affairs Medical Center. Medical records were abstracted to evaluate utilization of and contraindications to β-blocker, angiotensin-converting enzyme inhibitor, aldosterone antagonist, anticoagulation for atrial fibrillation, implantable cardioverter-defibrillator, and cardiac resynchronization therapies.
  
  
  RESULTS
  Of the 178 patients with HF and an ejection fraction ≤45%, 78 (44%) received every guideline-recommended therapy. After accounting for medical contraindications, 77 (72%) of 107 patients received every guideline-recommended therapy. Adherence to recommendations for β-blocker (98%), angiotensin-converting enzyme inhibitor/angiotensin blocker (95%), and anticoagulation (97%) were better than adherence to implantable cardioverter-defibrillator (82%), cardiac resynchronization therapy (59%), or aldosterone antagonist (51%) recommendations. In adjusted analysis, lower New York Heart Association functional class and care by a cardiologist were associated with improved guideline adherence (P < .001).
  
  
  CONCLUSIONS
  Many patients with HF have therapeutic contraindications, and a failure to account for these may lead to a large underestimation of the true guideline adherence rates.
authors.affiliation: Division of Cardiology, Duke University Medical Center, Durham, NC, USA. brett.atwater@duke.edu
authors.forename: Brett D
authors.initials: BD
authors.lastname: Atwater
authors.forename: David
authors.initials: D
authors.lastname: Dai
authors.forename: Nancy M
authors.initials: NM
authors.lastname: Allen-Lapointe
authors.forename: Sana M
authors.initials: SM
authors.lastname: Al-Khatib
authors.forename: Louise O
authors.initials: LO
authors.lastname: Zimmer
authors.forename: Gillian D
authors.initials: GD
authors.lastname: Sanders
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage; D000925:Anticoagulants / Q000008:administration & dosage; D058406:Cardiac Resynchronization Therapy; D002317:Cardiovascular Agents / Q000008:administration & dosage*; D000075202:Contraindications; D017147:Defibrillators, Implantable; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006333:Heart Failure / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D000451:Mineralocorticoid Receptor Antagonists / Q000008:administration & dosage; D012720:Severity of Illness Index
chemical_list: D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000925:Anticoagulants; D002317:Cardiovascular Agents; D000451:Mineralocorticoid Receptor Antagonists