title: Dose matters! Optimisation of guideline adherence is associated with lower mortality in stable patients with chronic heart failure.
abstract: OBJECTIVE
  Guidelines have been published for improving management of chronic heart failure (CHF). We examined the association between improved guideline adherence and risk for all-cause death in patients with stable systolic HF.
  
  
  METHODS
  Data on ambulatory patients (2006-2010) with CHF and reduced ejection fraction (HF-REF) from the Austrian Heart Failure Registry (HIR Austria) were analysed. One-year clinical data and long-term follow-up data until all-cause death or data censoring were available for 1014 patients (age 65 [55-73], male 75%, NYHA class I 14%, NYHA II 56%, NYHA III/IV 30%). A guideline adherence indicator (GAI [0-100%]) was calculated for each patient at baseline and after 12 ± 3 months that considered indications and contraindications for ACE-I/ARB, beta blockers, and MRA. Patients were considered ΔGAI-positive if GAI improved to or remained at high levels (≥ 80%). ΔGAI50+ positivity was ascribed to patients achieving a dose of ≥ 50% of suggested target dose.
  
  
  RESULTS
  Improvements in GAI and GAI50+ were associated with significant improvements in NYHA class and NT-proBNP (1728 [740-3636] to 970 [405-2348]) (p<0.001). Improvements in GAI50+, but not GAI, were independently predictive of lower mortality risk (HR 0.55 [95% CI 0.34-0.87; p=0.01]) after adjustment for a large variety of baseline parameters and hospitalisation for heart failure during follow-up.
  
  
  CONCLUSIONS
  Improvement in guideline adherence with particular emphasis on dose escalation is associated with a decrease in long-term mortality in ambulatory HF-REF subjects surviving one year after registration.
authors.affiliation: Clinical Division of Cardiology, Innsbruck Medical University, Austria.
authors.forename: G
authors.initials: G
authors.lastname: Poelzl
authors.affiliation: Department of Cardiology, Paracelsus Medical University Salzburg, Austria; Center for Cardiac Rehabilitation, Pensionsversicherungsanstalt, Grossgmain, Austria.
authors.forename: J
authors.initials: J
authors.lastname: Altenberger
authors.affiliation: Clinical Division of Cardiology, Vienna Medical University, Austria.
authors.forename: R
authors.initials: R
authors.lastname: Pacher
authors.affiliation: Department of Cardiology, St. Elisabeth Hospital, Linz, Austria.
authors.forename: C H
authors.initials: CH
authors.lastname: Ebner
authors.affiliation: Department of Cardiology, Krems General Hospital, Austria.
authors.forename: M
authors.initials: M
authors.lastname: Wieser
authors.affiliation: Department of Cardiology, Hospital of the Sisters of Charity, Linz, Austria.
authors.forename: A
authors.initials: A
authors.lastname: Winter
authors.affiliation: Department of Cardiology, Graz Medical University, Austria.
authors.forename: F
authors.initials: F
authors.lastname: Fruhwald
authors.affiliation: 2nd Department of Medicine, Hanusch Hospital, Vienna, Austria.
authors.forename: C
authors.initials: C
authors.lastname: Dornaus
authors.affiliation: Private practice, Vienna, Austria.
authors.forename: U
authors.initials: U
authors.lastname: Ehmsen
authors.affiliation: Department of Cardiology, Kaiser Franz Josef Hospital, Vienna, Austria.
authors.forename: S
authors.initials: S
authors.lastname: Reiter
authors.affiliation: Department of Cardiology, Paracelsus Medical University Salzburg, Austria.
authors.forename: R
authors.initials: R
authors.lastname: Steinacher
authors.affiliation: Clinical Division of Cardiology, Vienna Medical University, Austria.
authors.forename: M
authors.initials: M
authors.lastname: Huelsmann
authors.affiliation: Department of Cardiology, St. Elisabeth Hospital, Linz, Austria.
authors.forename: V
authors.initials: V
authors.lastname: Eder
authors.affiliation: Department of Cardiology, Krems General Hospital, Austria.
authors.forename: A
authors.initials: A
authors.lastname: Boehmer
authors.affiliation: Department of Cardiology, Hospital of the Sisters of Charity, Linz, Austria.
authors.forename: L
authors.initials: L
authors.lastname: Pilgersdorfer
authors.affiliation: Department of Cardiology, Graz Medical University, Austria.
authors.forename: K
authors.initials: K
authors.lastname: Ablasser
authors.affiliation: Private practice, Vienna, Austria.
authors.forename: D
authors.initials: D
authors.lastname: Keroe
authors.affiliation: Department of Internal Medicine, St. Johann County Hospital, Austria.
authors.forename: H
authors.initials: H
authors.lastname: Groebner
authors.affiliation: Department of Cardiology and Intensive Care, Braunau General Hospital, Austria.
authors.forename: J
authors.initials: J
authors.lastname: Auer
authors.affiliation: 3rd Department of Medicine, Wilhelminenspital, Vienna, Austria.
authors.forename: G
authors.initials: G
authors.lastname: Jakl
authors.affiliation: Department of Internal Medicine and Cardiology, Donauklinikum Tulln, Austria.
authors.forename: A
authors.initials: A
authors.lastname: Hallas
authors.affiliation: Clinical Division of Cardiology, Innsbruck Medical University, Austria.
authors.forename: M
authors.initials: M
authors.lastname: Ess
authors.affiliation: Department of Medical Statistics, Informatics and Health Economics, Innsbruck Medical University, Austria.
authors.forename: H
authors.initials: H
authors.lastname: Ulmer
mesh_terms: D000368:Aged; D001315:Australia / Q000453:epidemiology; D002317:Cardiovascular Agents / Q000008:administration & dosage*; D002908:Chronic Disease; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence / Q000639:trends*; D006333:Heart Failure / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality*; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D012042:Registries
chemical_list: D002317:Cardiovascular Agents
keywords: Chronic heart failure; Guideline adherence indicator; Prognosis; Treatment adjustment