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Risk-Treatment Mismatch in the Pharmacotherapy of Heart Failure
Douglas S. Lee, MD, PhD;
Jack V. Tu, MD, PhD;
David N. Juurlink, MD, PhD;
David A. Alter, MD, PhD;
Dennis T. Ko, MD;
Peter C. Austin, PhD;
Alice Chong, BSc;
Therese A. Stukel, PhD;
Daniel Levy, MD;
Andreas Laupacis, MD, MSc
JAMA. 2005;294:1240-1247.
Context Patients with heart failure have a wide spectrum of mortality risks. To maximize the benefit of available pharmacotherapies, patients with high mortality risk should receive high rates of drug therapy.
Objective To examine patterns of drug therapy and underlying mortality risk in patients with heart failure.
Design, Setting, and Patients In the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) population-based cohort (1999-2001) of 9942 patients with heart failure hospitalized in Ontario, Canada, we evaluated 1418 patients with documented left ventricular ejection fraction of 40% or less and aged 79 years or younger with low-, average-, and high-predicted risk of death within 1 year; all patients survived to hospital discharge. Administration of angiotensin-converting enzyme (ACE) inhibitors, ACE inhibitors or angiotensin II receptor blockers (ARBs), and  -adrenoreceptor antagonists was evaluated according to predicted risk of death.
Main Outcome Measure Heart failure drug administration rates at time of discharge and 90 days after hospital discharge.
Results At hospital discharge, prescription rates for patients in the low-, average-, and high-risk groups were 81%, 73%, 60%, respectively, for ACE inhibitors; 86%, 80%, 65%, respectively, for ACE inhibitors or ARBs; and 40%, 33%, 24%, respectively, for -adrenoreceptor antagonists (all P<.001 for trend). Within 90 days following hospital discharge, the rates were 83%, 76%, and 61% for ACE inhibitors; 89%, 83%, and 67% for ACE inhibitors or ARBs; and 43%, 36%, and 28% for -adrenoreceptor antagonists for the 3 risk groups, respectively (all P<.001 for trend). The pattern of lower rates of drug administration in those patients at increasing risk was maintained up to 1 year postdischarge (P<.001). After accounting for varying survival time and potential contraindications to therapy, low-risk patients were more likely to receive ACE inhibitors or ARBs (adjusted hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.49-1.74) and -adrenoreceptor antagonists (HR, 1.80; 95% CI, 1.60-2.01) compared with high-risk patients (both P<.001).
Conclusions Patients with heart failure at greatest risk of death are least likely to receive ACE inhibitors, ACE inhibitors or ARBs, and -adrenoreceptor antagonists. Understanding the reasons underlying this mismatch may facilitate improvements in care and outcomes for patients with heart failure.
Author Affiliations: Institute for Clinical Evaluative Sciences (Drs Lee, Tu, Juurlink, Alter, Ko, Austin, Stukel, and Laupacis, and Ms Chong), Department of Health Policy, Management, and Evaluation, University of Toronto (Drs Tu, Juurlink, Alter, Austin, Stukel, and Laupacis), and Sunnybrook and Women’s College Health Sciences Centre, University of Toronto (Drs Tu, Juurlink, Alter, Ko, and Laupacis), Toronto, Ontario; and the Framingham Heart Study of the National Heart, Lung, and Blood Institute, National Institutes of Health, Framingham, Mass (Drs Lee and Levy).
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