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More patients need beta-blockers, ACE inhibitors
You’re busy, perhaps too busy. You have so many demands on your time and so many pieces of paper on your desk that it’s impossible to keep up. Who has time to read a 30- or 40-page set of guidelines for the treatment of CHF?
Two sets of guidelines have been published in the last year — one in the Journal of Cardiac Failure (1999; 5:357-382) and the other in the American Journal of Cardiology (1999; 83:2A). A third set from the American College of Cardiology (ACC) and the American Heart Association (AHA), published in 1995, is being revised now and should be published by the end of this year. That’s a lot to keep up with, but you should try, experts say.
"One of the problems of heart failure management is extreme variability in care," says Marc Silver, MD, director of the Heart Failure Institute at Christ Hospital and Medical Center in Oak Lawn, IL. Silver helped draft both of the new guidelines and is on the committee for the ACC/AHA set.
"Adherence to guidelines is not that great. Part of that is a distribution problem and part of it is that people just don’t have time to read them. But the treatment of heart failure is not totally subject to opinion. There are different ways to skin a cat, but there are not that many ways."
The good thing about the new sets of guidelines is that they deliver a consistent message although they are written for different target audiences, Silver says. That message includes:
• All patients with left ventricular systolic dysfunction should be given ACE inhibitors and beta-blockers unless they are intolerant of the drugs or have a contraindication to their use. Currently only 40% of patients with heart failure receive ACE inhibitors, and fewer than 5% receive beta-blockers.
• Physicians should work to titrate diuretics to the right dose and monitor the use of the drugs carefully. These drugs should not be used alone, even if they are effective in controlling symptoms.
• Most patients need a small amount of digoxin — in most patients, the dose should be 0.125 mg to 0.25 mg and no higher.
• Angiotensin II receptor blockers are useful drugs but should not be considered primary treatment.
• Patients should be encouraged to exercise, which can provide a number of benefits, including a reduction in neurohormonal activation. Excessive bed rest is not recommended for patients with heart failure.
• Left ventricular chamber size should be documented in every patient.
• Patients should receive an echocardiogram.
• Physicians should seek to understand the risk, benefits, and nuances of heart failure drugs, which are explained in the guidelines.
Which guideline should you read? The paper in the American Journal of Cardiology, "Consensus Recommendations for the Management of Chronic Heart Failure," was intended to be a comprehensive approach to CHF care that would be especially helpful for primary care physicians and cardiologists. (See box, above right.)
This guideline emphasizes recognition and early diagnosis of the disease as well as nonpharmacologic therapy. It was edited by Milton Packer, MD, of Columbia University in New York City, and Jay Cohn, MD, of the University of Minnesota in Minneapolis, and was reviewed by more than 150 heart failure specialists.
The paper in the Journal of Cardiac Failure was written by a committee of the Minneapolis-based Heart Failure Society of America and is directed at heart failure specialists who need updates on new issues as opposed to comprehensive recommendations. This guideline emphasizes correct use of drug therapy, especially beta-blockers and ACE inhibitors.
The beta-blocker issue is a tough one, but it’s vital to CHF treatment, Cohn says. "Tradition has suggested that beta-blockers are not good to be given to people in heart failure, and that’s a hard concept to reverse," he says. "Most patients with heart failure are being taken care of by primary care doctors who may be less comfortable using these drugs. There are some downside risks to the drugs. The patients must be carefully monitored and told that they might not feel better at first and may, in fact, feel worse. A lot of physicians are reluctant to embark on this therapy, and they need to have confidence and that’s going to take time."
Silver says the guideline writers don’t want the same mistakes to be made with beta-blockers as have been made with ACE inhibitors. "We looked back at what we have learned with ACE inhibitors, and it seemed like we were going down the same path with beta-blockers," he says.
"Our first trials with ACE inhibitors were in people with functional Class IV and then we moved back to people with mild-to-moderate heart failure and then mild heart failure and then to asymptomatic patients. We kept learning the same lesson: The earlier we use these drugs, the better off the patient is. We felt it was the same story with beta-blockers in that we shouldn’t wait another five or 10 years until that message was clear from data," says Silver.
Bill Abraham, MD, associate professor and director of the heart failure and transplant program at the University of Cincinnati Medical Center and one of the reviewers of the consensus guidelines, gives another reason why physicians should read these documents. "Guidelines are always two to three years behind the standard of care. For example, European guidelines discussed the importance of beta-blockers in heart failure in 1997," he says.
"Guidelines often don’t get used. I saw a survey that asked hospitals how many of them had inpatient pathways, and the number was 100%. But then it asked how many used those pathways, and the number was 20%. You need a person, a champion, who is invested in heart failure care to facilitate having the right thing done. It takes a grass-roots effort and a personal commitment."