Loading

Journal of Family Medicine and Community Health

A Study to Assess Limitations in the Adherence to 2013 American College of Cardiology Foundation or American Heart Association Practice Guideline for Management of Heart Failure in Primary Care

Mini Review | Open Access | Volume 4 | Issue 1

  • 1. Department of Medicine, Wright Center for Graduate Medical Education, USA
+ Show More - Show Less
Corresponding Authors
Samir B. Pancholy, Department of Medicine, Section of Cardiology, The Wright Center for Graduate Medical Education, 501 Madison avenue, Scranton PA 18510, USA.
Citation

Valadri R, Litchman M, Spring D, Singhania N, Nardella JA, et al. (2017) A Study to Assess Limitations in the Adherence to 2013 American College of Cardiology Foundation/American Heart Association Practice Guideline for Management of Heart Failure in Primary Care. J Family Med Community Health 4(1): 1101.

Keywords
  • HFpEF
  • HFrEF
  • ACCF/AHA HF guideline adherence
  • Primary care

 

ABBREVIATIONS

ACCF/AHA: American College of Cardiology Foundation/ American Heart Association; HFpEF: Heart failure with preserved Ejection Fraction; HFrEF: Heart Failure with reduced Ejection Fraction; BMI: Body Mass Index; DM: Diabetes Mellitus; CAD: Coronary Artery Disease; HTN: Hypertension; eGFR: estimated Glomerular Filtration Rate; BB: Beta Blockers; ACEI: Angiotensin Converting Enzyme Inhibitor; ARB: Aldosterone Receptor Blocker; BiDil: Isosorbide Dinitrate/hydralazine Hydrochloride; ICD: Implantable Cardioverter Defibrillator; CRT: Cardiac Resynchronization Therapy; GDMT: Guideline-Directed Medical Therapy; NYHA: New York Heart Association ; SCD: Sudden Cardiac Death; LBBB: Left Bundle Branch Block

INTRODUCTION

Heart failure (HF) has grown to epidemic proportion with approximately 650000, new cases diagnosed annually[1] and a prevalence increased from 90 to 121 per 1000 Medicare beneficiaries from 1994 to 2003[2]. Both HFrEF and HFpEF have been shown to equally contribute to the HF syndrome [3]. HF has become a public health problem with 50% absolute mortality within five years of diagnosis [4], greater than one million hospitalizations annually [1], 30-day all cause readmission rate of 25% [5] and an annual estimated cost of care exceeding $30 billion in the United States [1].

2013 ACCF/AHA guideline for HF recommendations

2013 ACCF/AHA guideline for HF provides comprehensive evidence-based recommendations for the management of HF stage A to D and device therapy for HF stage B to D [6]. In the current study we focused on HF stage C

Stage C HF comprises patients with structural heart disease and prior or current symptoms of HF. Class I recommendations include patient education on HF self-care [7], ACEI use in all patients with HFrEF [8,9], ARB use in HFrEF when ACEI is intolerable [10,11], HF specific BB use in all patients with HFrEF [12-15]. Aldosterone antagonists are recommended in patients with New York Heart Association (NYHA) functional class II-IV symptoms with EF≤ 35% [16], in diabetic patients with history of MI with HF symptoms and EF ≤ 40% [17]. The combination of Hydralazine and Isosorbide dinitrate (BiDil) is recommended in African Americans (AA) with HFrEF and NYHA functional class III–IV symptoms despite optimal medical therapy [18,19]. Diuretic use and chronic oral anticoagulation is recommended in appropriate clinical setting [20,21]. Class IIa recommendations include exercise training to improve functional capacity [22], and use of continuous positive airway pressure (CPAP) to improve LVEF and functional status in patients with concomitant obstructive sleep apnea (OSA) [23]. Class I recommendation for device therapy include ICD for primary prevention of sudden cardiac death (SCD) in selected patients with HFrEF who are at least 40 days post-MI with LVEF ≤ 35% and NYHA functional class II or III symptoms [24,25], or patients with LVEF ≤ 30% and NYHA class I symptoms [26], while on optimal medical therapy and who are expected to live >1 year. CRT with defibrillator device is recommended for patients with LVEF ≤ 35%, sinus rhythm, left bundle branch block (LBBB) with a QRS ≥ 150 ms and NYHA functional class II or III symptoms or ambulatory class IV symptoms despite optimal medical therapy [27,28].

Class I recommendation in HFpEF include systolic and diastolic BP control in accordance with published clinical practice guidelines to prevent morbidity [29,30] and diuretic use for symptom relief.

Adherence to 2013 ACCF/AHA guideline for management of HF has shown to be associated with improved outcomes in patients with chronic HF6 .We sought to evaluate the guideline adherence and limitations in adherence in our clinic.

Pre-specified definitions

Definitions for HFpEF and HFrEF were LVEF ≥ 50% and LVEF<50% respectively [6]. Medical therapy was defined as suboptimal in HFrEF when maximal tolerable dose at the most recent clinic visit was <75% of the guideline recommended dose. Recommended maximal tolerable medical therapy in HFrEF for ACEI is: lisinopril, enalapril, quinapril and fosinopril20 mg/day, captopril150 mg/day and ramipril 10 mg/day. For ARB: valsartan320 mg/day and losartan100 mg/day. For BB: metoprolol succinate and metoprolol tartrate200 mg/day, carvedilol50 mg/day, carvedilol phosphate extended release80 mg/day andbisoprolol10 mg/day. Recommended dose for spironolactone 50 mg/day. Recommended dose for BiDil: 300 mg/day for Hydralazine and 120 mg/day for Isosorbide dinitrate. In HFpEF, medical therapy was considered suboptimal when the BP was >150/90 mm Hg. Although there is no specific target blood pressure defined in HFpEF, we chose a target BP<150/90 mm Hg based on JNC 8 guidelines [31]. Permissible hemodynamics and renal function to consider up-titration of medical therapy in HFrEF defined as systolic BP of ≥ 100 mm HG, resting HR ≥ 70 bpm and/or a serum creatinine< 3 mg/dL respectively.

METHODS

Study was approved by the local institutional review board which waived the consenting process, based on less than minimal risk to patient safety and privacy. EMRs of patients with chronic HF were reviewed starting from their most recent clinic visit to at least three consecutive visits in retrospect. The rationale for three visits was to give an opportunity to achieve maximal tolerable optimal medical and device therapy. Limitations in adherence to 2013 ACCF/AHA guideline for HF [6] in individual patients were assessed in following clinical indicators.

We assessed the proportion of HFrEF patients on guideline directed medical therapy, proportion of patients with maximal tolerable medical therapy in terms of HF specific BB, ACEI/ARB and aldosterone antagonist and AA patients on BiDil and appropriate device therapy in terms of ICD and CRT when indicated [27,28]. Proportion of HFpEF patients with optimal BP control as defined above were assessed. In both HF phenotypes, we assessed the proportion of patients who had optimal hemodynamic status, who received 60 minutes HF self-care education at post-hospital discharge, saw their PCP within seven days of hospital discharge, who were current with pneumococcal and influenza vaccination status and used CPAP if diagnosed with OSA.

Statistical analysis

IBM-SPSS version 22, Chicago, IL was used for the statistical analysis. Analysis was primarily exploratory to describe the cohort characteristics and express proportion of patients with guideline adherence. Categorical variables were expressed as frequencies and proportions and continuous variables as mean ± standard deviation.

RESULTS

Cohort consisted 163 patients with chronic HF. Eight patients were excluded for lack of adequate clinic visits, resulting in 155 patients for the analysis. Mean (± SD) age of the cohort was 62.5(±12.9) years and 65(41.9%) were females. Patients with HFpEF dominated the cohort compared to HFrEF (82(52.9%) Vs. 73(47.1%); P=0.0001). Baseline characteristics are shown in Table (1).

In evaluating guideline adherence in HFrEF we found that there were51(86.4%) patients on HF specific BB, 44(60.3%)patients on ACEI/ARBs, 7(9.6%) patients on spironolactone and one AA patient was on Bidil. NYHA functional class was not routinely documented to determine whether appropriate therapies and/ or up-titration of dose were considered. Guideline recommended maximal tolerable dose was achieved only in 8(13.6%) patients with BB, in 24(66.7%) patients with ACEI, in 1(12.5%) patient with ARB and in 5(25%) patients with spironolactone. These statistics were in patients with permissible hemodynamics and serum creatinine which would have allowed up-titration of the medication dose. ICD was not used in 35(77.8%) patients and CRT was not used in 15(83.3%) patients despite a clinical indication per the guideline [27,28,30].

In patients with HFpEF, adherence to the guideline of optimal BP control (< 150/90 mm Hg) was achieved in 72(87.8%) patients. In HFrEF 55(75.3%) patients had BP <150/90 mm Hg, but only 23(31.5%) patients had HR ≤ 70. Unadjusted all-cause deaths were 13% and 18% in patients with HFrEF and HFpEF respectively (P=0.43).

Guideline adherence was acceptable in terms of prompt PCP visit scheduling within seven days of hospital discharge (100%) and pneumococcal immunization 115(74.2%). However, influenza immunization varied between 12% to 70% with decline in recent seasons. Documented LVEF and an EKG within past year present in 129(83.2%) and 146 (94.2%) patients respectively. Diabetes was present in 84(54.2%) patients and 62(73.8%) off these were on metformin therapy. Average diabetes control was acceptable with a mean HbA1Cof 7.2. Chronic AF requiring anticoagulation as per the guidelines [20,21], was present in 44(28.3%) patients. Only 15(34.1%) patients were on an anticoagulation agent. Reasons for lack of anticoagulation were not documented in at least 50% of the cases. OSA was present in 13(8.4%) patients. CPAP use was less than 50% in this group. Documentation of a referral for formal exercise training, cardiac rehabilitation, NYHA functional classification and scheduled device interrogations in patients with ICD and CRT therapy were not readily available.

Table 1: Baseline characteristics (N=155).

  Parameter  HFrEF; N=73 (47.1%)  HFpEF N= 82 (52.9%)
Age (±SD) years 62.5 (±12.9) 64.4±12.5
LVFF (±SD) % 31.0 (8±10.3) 58.8±4.4
SBP (±SD) mm HG 132.6±25.4 128.5±20.6
DBP (±SD) mm HG 76.2±13.6 73.7±11.7
HR (±SD) beats/min 79.5±13.3 76.9±10.6
Serum Na (±SD) mEq/ dL 137.3±4.2 137.1±4.9
Serum BUN (±SD) mg/ dL 29.3±24.3 27.6±21.4
Serum Cr (±SD) mg/dL 1.6±1.2 1.9±2.1
eGFR (±SD) ml/ min/1.23 m² 56.1±30.0 54.2±27.8
BNP (±SD) ng/dL 868.9±1213.5 497.9±580.0
BMI (±SD) Kg/m² 32.3±8.5 34.6±11.9
A1C (±SD) 7.2±1.4 7.6±2.2
Female 30 (41.1%) 35 (42.7%)
DM 41 (56.2%) 43 (52.4%)
HTN 65 (89.0%) 74 (90.2%)
CAD 46 (63.0%) 54 (65.9%)
Dyslipidemia 50 (68.5%) 50 (61.0%)
AF 14 (19.2%) 20 (24.4%)
OSA 7 (9.6%) 6 (7.3%)
Smoking 26 (35.6%) 27 (32.9%)
Aspirin 18 (24.7%) 18 (22.0%)
Statin 18 (24.7%) 27 (32.9%)
BB 28 (38.4%) 32 (39.0%)
ACEI 36 (49.3%) 44 (41.5%)
ARB 4 (5.5%) 3 (3.7%)
Aldactone 7 (9.6%) 4 (4.9%)
Diuretics 17 (23.3%) 24 (29.3%)
Metformin (in DM) 32 (43.8%) 32(39%)
Insulin (in DM) 2 (4.8%) 16 (19.5%)
Anticoagulation 8 (11.0%) 11 (13.4%)

 

DISCUSSION

Principal finding of our analysis is that, there appears to be inconsistency in documentation of the provider’s consideration for the guideline directed therapies and reasons for not applying in certain patients with chronic HF. This may contribute to the perception that there is lack of adherence and failure to consider in future appropriate management options. Documentation for guideline adherence was acceptable of initiation of BB but fell short in terms of initiation of ACEI/ARB in HFrEF. Most importantly, there was inconsistent documentation that uptitration was considered. Initiation and up-titration to maximal tolerable dose are equally important to derive the morbidity and mortality benefits demonstrated in RCTs [6]. Adherence to the guideline was acceptable regarding scheduling post hospital office visit and being current with pneumococcal vaccine. The percentage of patients current with receiving Influenza immunization was below the guideline accepted level. Suboptimal influenza immunization rate was most commonly due to patient refusal. Blood Pressure was optimally controlled in HFpEF. Our study is in accordance with recent study by Komajda et al. [32], where significant lag in guideline adherence was noted in optimal medication dosing in patients with chronic HF. Our study fills the gap in the evidence by providing information on the perception that there is lack of adherence in primary care practice and in the United States patient population.

Primary care provider is the cornerstone in optimizing medical care, coordinating care, disease progression surveillance and in making timely referrals to sub-specialists as needed. Uptitration of guideline directed medical therapy requires close monitoring of hemodynamics, symptoms, functional assessment, volume status and diagnostic studies which require frequent visits. Primary care physician plays a crucial role, in disease management and up-titration because seeing a specialist at closer intervals may not be practical. Therefore, it is crucial to empower the primary care provider to improve the quality of care in chronic heart failure.

Patient related factors for perceived non adherence to guideline are multifactorial. It has been documented that many patients do not tolerate the doses of neurohormonal antagonists documented in the trials, despite vigorous efforts [33]. Patient non-compliance with clinic visits, diagnostic testing and keeping up with sub-specialists could negatively affect the guideline adherence. Primary care physician is less likely to up-titrate medication dose in a stable, asymptomatic HF patient because of potential concern about tipping the balance of cardio-renal homeostasis. Patient level factors which contribute to suboptimal therapy include lack of knowledge on their disease and its natural course, lack of insurance coverage for certain medications, failure to adequately address co morbid conditions. Scheduling closer appointments with primary care physician will help with up-titration of medication, with monitoring NYHA functional class, detecting EKG changes and assessing LVEF. These are key variables that prompt escalation of the medical and device therapy when indicated.

System improvement measures after the analysis

Measures were initiated to educate resident physicians on updated HF practice guidelines [6,34], proper assessment and documentation of NYHA functional class at every clinic visit and on recommendations for periodic echocardiographic and electrocardiographic surveillance. Measures were initiated to refer patients to cardiac rehabilitation and have our local hospital participate with the American Heart Association Get With The Guidelines-Heart Failure (AHA GWTG-HF) [6], Program to improve quality of care in CHF in-patients.

Limitations

Our study results should be interpreted in the context of following limitations. The study was limited to one primary care office with a low sample size, predominantly consisting of patients with Medicare. Therefore, may not be applicable to other clinical settings with different insurance coverage. The retrospective nature of the study could have resulted in unmeasured confounding variables and some degree of selection bias that could have affected some of the results. Patient’s race was not documented on most of the patients to determine the race based indication of BiDil in AA patients with HFrEF [18,19]. Many patients were also seen by cardiologists as outpatients. Dynamic changes in therapy by cardiologists were not always accessible which could have affected the study results. Medication tolerance was only defined in terms of hemodynamics and renal function. Data on patient reported symptoms were not documented consistently. So it is unknown how much it contributed to the results. Similarly, data on Insurance limitations, patient compliance and preference was not available which can limit the use of optimal medical therapy. BB use for other indications other than HF such as prophylaxis for refractory migraine and variceal bleed prevention and spironolactone use for hyperaldosteronism could have inadvertently influenced hemodynamics, limiting the up-titration of optimal HF therapy.

CONCLUSION

There appears to be a lag in the evidence for adherence to the 2013ACCF/AHA guideline for management of chronic HF in Primary Care. System improvement measures should be implemented to improve documentation on consideration of guidelines and limitations in individual patients so as to improve the guideline adherence.

REFERENCES

1. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics--2013 update: a report from the American Heart Association. Circulation. 2013; 127: e6-e245.

2. Curtis LH, Whellan DJ, Hammill BG, Hernandez AF, Anstrom KJ, Shea AM, et al. Incidence and prevalence of heart failure in elderly persons, 1994-2003. Archives of internal medicine. 2008; 168: 418-424.

3. Owan TE, Redfield MM. Epidemiology of diastolic heart failure. Prog Cardiovasc Dis. 2005; 47: 320-332.

4. Roger VL, Weston SA, Redfield MM, Hellermann-Homan JP, Killian J, Yawn BP, et al. Trends in heart failure incidence and survival in a community-based population. Jama. 2004; 292: 344-350.

5. Krumholz HM, Merrill AR, Schone EM, Schreiner GC, Jersey Chen, Elizabeth H, et al. Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circulation Cardiovascular quality and outcomes. 2009; 2: 407-413.

6. Yancy CW, Jessup M, Bozkurt B, Javed Butler, Casey DE, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013; 128: 240-327.

7. Boren SA, Wakefield BJ, Gunlock TL, Wakefield DS. Heart failure self-management education: a systematic review of the evidence. Int J Evid Based Healthc. 2009; 7:159-168.

8. Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group. The New England journal of medicine. 1987; 316:1429-1435.

9. Cohn JN, Johnson G, Ziesche S, Frederick Cobb, Gary Francis, Felix Tristani, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. The New England journal of medicine. 1991; 325: 303-310.

10. Cohn JN, Tognoni G. A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. The New England journal of medicine. 2001; 345: 1667-1675.

11. Pfeffer MA, McMurray JJ, Velazquez EJ, Jean-Lucien Rouleau, Lars Køber, Aldo P. Maggioni, et al. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. The New England journal of medicine. 2003; 349: 1893-1906.

12. Xamoterol in severe heart failure. The Xamoterol in Severe Heart Failure Study Group. Lancet (London, England). 1990; 336: 1-6.

13. Effects of carvedilol, a vasodilator-beta-blocker, in patients with congestive heart failure due to ischemic heart disease. Australia-New Zealand Heart Failure Research Collaborative Group. Circulation. 1995; 92: 212-218.

14. A trial of the beta-blocker bucindolol in patients with advanced chronic heart failure. The New England journal of medicine. 2001; 344: 1659-1667.

15. Poole-Wilson PA, Swedberg K, Cleland JG, Di Lenarda A, Hanrath P,Komajda M, et al. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol or Metoprolol European Trial (COMET): randomised controlled trial. Lancet (London, England). 2003; 362: 7-13.

16. Pitt B, Zannad F, Remme WJ, Robert Cody, Alain Castaigne, Alfonso Perez, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. The New England journal of medicine. 1999; 341: 709-717.

17. Pitt B, Remme W, Zannad F, James Neaton, Felipe Martinez, Barbara Roniker, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. The New England journal of medicine. 2003; 348: 1309-1321.

18. Carson P, Ziesche S, Johnson G, Cohn JN. Racial differences in response to therapy for heart failure: analysis of the vasodilator-heart failure trials. Vasodilator-Heart Failure Trial Study Group. Journal of cardiac failure. 1999; 5: 178-187.

19. Taylor AL, Ziesche S, Yancy C, Peter Carson, Ralph D’Agostino, Keith Ferdinand, et al. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. The New England journal of medicine. 2004; 351: 2049-2057.

20. Granger CB, Alexander JH, McMurray JJ, Renato D. Lopes, Elaine M. Hylek, Michael Hanna, et al. Apixaban versus warfarin in patients with atrial fibrillation. The New England journal of medicine. 2011; 365: 981-992.

21. Patel MR, Mahaffey KW, Garg J, Guohua Pan, Daniel E. Singer, Werner Hacke, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. The New England journal of medicine. 2011; 365: 883- 891.

22. Davies EJ, Moxham T, Rees K, Singh S, Coats AJ, Ebrahim S, et al. Exercise training for systolic heart failure: Cochrane systematic review and meta-analysis. European journal of heart failure. 2010; 12: 706-715.

23. Arzt M, Floras JS, Logan AG, Kimoff RJ, Series F, Morrison D, et al. Suppression of central sleep apnea by continuous positive airway pressure and transplant-free survival in heart failure: a post hoc analysis of the Canadian Continuous Positive Airway Pressure for Patients with Central Sleep Apnea and Heart Failure Trial (CANPAP). Circulation. 2007; 115: 3173-3180.

24. Moss AJ, Zareba W, Hall WJ, Helmut Klein, Wilber DJ, Cannom DS, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. The New England journal of medicine. 2002; 346: 877-883.

25. Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Robin Boineau, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. The New England journal of medicine. 2005; 352: 225-237.

26. MArthur J. Moss, W. Jackson Hall, David S. Cannom, James P. Daubert, Steven L. Higgins, Helmut Klein, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. The New England journal of medicine. 1996; 335: 1933-1940.

27. Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Evan Loh, et al. Cardiac resynchronization in chronic heart failure. The New England journal of medicine. 2002; 346: 1845-1853.

28. Tang AS, Wells GA, Talajic M, et al. Cardiac-resynchronization therapy for mild-to-moderate heart failure. The New England journal of medicine. 2010; 363: 2385-2395.

29. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension (Dallas, Tex: 1979). 2003; 42: 1206-1252.

30. Levy D, Larson MG, Vasan RS, Kannel WB, Ho KK. The progression from hypertension to congestive heart failure. Jama. 1996; 275: 1557- 1562.

31. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Jama. 2014; 311: 507-520.

32. Komajda M, Anker SD, Cowie MR, Filippatos GS,Mengelle B,Ponikowski P, et al. Physicians’ adherence to guideline-recommended medications in heart failure with reduced ejection fraction: data from the QUALIFY global survey. European journal of heart failure. 2016; 18: 514-522.

33. Gupta R, Tang WH, Young JB. Patterns of beta-blocker utilization in patients with chronic heart failure: experience from a specialized outpatient heart failure clinic. American heart journal. 2004; 147: 79- 83.

34. Roth GA, Poole JE, Zaha R, Zhou W, Skinner J, Morden NE. Use of Guideline-Directed Medications for Heart Failure Before Cardioverter-Defibrillator Implantation. Journal of the American College of Cardiology. 2016; 67: 1062-1069.

Abstract

Background: Adherence to evidence-based American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guideline for management of chronic heart failure (HF) has shown to be associated with improved outcomes. We sought to assess the limitations in the adherence to the guideline in our primary care clinic.

Methods: Electronic medical records (EMR) of chronic HF patients with at least 3scheduled consecutive visits to primary care physician (PCP) office within past 2 years at a family medicine residency program were reviewed in a retrospective observational study. Data from the most recent clinic visit was analyzed to assess limitations associated with adherence to the2013 ACCF/AHA guideline directed medical and device therapy.

Results: Analysis included 155 patients. There were 73(47.1%) patients with heart failure with reduced ejection fraction (HFrEF) and 82(52.9%) patients with heart failure with preserved ejection fraction (HFpEF). In HFrEF group, 51 (86.4%) patients were on HF specific beta blockers (BB), 44 (60.3%) were on angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARBs), 7(9.6%) were on spironolactone. Maximal tolerable dose was achieved only in 8(13.6%) patients with BBs, 24(66.7%) patients with ACEIs,1(12.5%) patient with ARBs and 5(25%) patients with spironolactone. Despite clinical indication as per the guideline, implantable cardioverter defibrillator (ICD) was not used in 35(77.8%) patients and cardiac resynchronization therapy (CRT) was not used in 15(83.3%) patients. In patients with HFpEF, optimal BP (SBP<150/90 mm Hg) was achieved in 72 (87.8%) patients. Documentation of individual patient level factors such as tolerance, compliance, and insurance-related factors that potentially limit adherence to the guideline, was not readily available.

Conclusions: There appears to be a lag in the evidence for adherence to the 2013 ACCF/AHA guideline for management of chronic HF in Primary Care. System improvement measures should be implemented to improve documentation of management decisions made. Documentation should acknowledge consideration of recommended guidelines & provider’s rationale for adhering or deviating from them.
 

Valadri R, Litchman M, Spring D, Singhania N, Nardella JA, et al. (2017) A Study to Assess Limitations in the Adherence to 2013 American College of Cardiology Foundation/American Heart Association Practice Guideline for Management of Heart Failure in Primary Care. J Family Med Community Health 4(1): 1101

Received : 14 Oct 2016
Accepted : 16 Feb 2017
Published : 20 Feb 2017
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X