Heart failure is a common, distressing and disabling illness and is associated with worse outcomes than many forms of cancer. In simple terms it can be described as a condition in which the heart muscle progressively loses the ability to pump enough blood to meet the oxygen and other needs of the body. It is estimated that up to 50 million of the 1000 million people (5%) who inhabit the 47 nations of the European Society of Cardiology may have a heart failure related problem.3
For many patients the prognosis is poor: it is estimated that 50 per cent of patients with heart failure will die within five years. It is also a severe burden on healthcare resources. The direct costs of heart failure in developed countries is thought to be between 1 and 2% of the total healthcare budget, with a considerable proportion being attributable to hospitalisation costs.4 Although, with optimal treatment it is possible to reduce these costs and mortality. 4
Professor John McMurray, Professor of Medical Cardiology in the Clinical Research Initiative in Heart Failure at the University of Glasgow, Scotland, and a lead author of the guidance said: "Under-treatment of heart failure denies patients the benefits of current interventions and has an adverse health economic effect in terms of increased hospitalisations. The preparation of these concise, step-by-step practical clinical recommendations for the prescribing of ACE inhibitors and beta-blockers should provide doctors with the confidence to practise evidence-based medicine in patients with chronic heart failure."
A number of trials have provided strong clinical evidence for the use of angiotensin converting enzyme (ACE) inhibitors, beta-blockers and spironolactone to significantly improve survival and to decrease hospitalisations and sudden death. 5, 6, 7, 8, 9 10, 11 However, despite such evidence the adoption of such therapies into clinical prescribing has been slow and incomplete.
Clinical surveys conducted in different countries have revealed that substantial proportions of patients who should have been treated with ACE inhibitors were not receiving the treatment. It is thought that one of the main reasons for this is that doctors do not have easy-to-follow advice on the practicalities of prescribing such drugs and there may also be some unreasonable concern about possible adverse effects. It is precisely for these reasons that these new recommendations have been published.
Patients who are correctly treated for their heart failure often report a positive impact on their quality of life according to Professor Richard Hobbs, Professor of Primary Care and General Practice at the University of Birmingham, UK. "Many heart failure patients gain a new lease of life once their heart failure is adequately controlled. It is unfortunate that a majority of patients are either not offered or under-treated with interventions which would improve both the length and the quality of their lives. This new guidance is designed to answer common questions that non-specialist healthcare professionals may have regarding heart failure treatment and should, hopefully encourage more doctors, especially those in primary care, to adequately treat patients."
The guidance is based on a three-step process. It begins with the assumption that a diagnosis of heart failure has been made and diuretic treatment has been initiated. The first step is to confirm the presence of left ventricular systolic dysfunction. The second step entails starting first-line therapy, which consists of an ACE inhibitor followed by a beta-blocker. Both drugs should be introduced at low doses and then titrated up to the target doses as determined by large randomised trials. The guidance states that currently only three beta-blockers have been shown to reduce mortality and hospitalisations in heart failure, while others have been shown to be ineffective. Therefore, the benefits of beta-blockers can not be assumed to be a class effect. The third step in this practical guidance is the addition of second-line therapy for patients in whom there are persisting signs and symptoms of heart failure. Second-line therapy is spironolactone, initiated at a low dose and then titrated up.
The guidance has been produced with the help of a unrestricted educational grant from AstraZeneca.
AstraZeneca is a major international healthcare business engaged in the research, development, manufacture and marketing of ethical (prescription) pharmaceuticals and the supply of healthcare services. It is one of the top five pharmaceutical companies in the world with healthcare sales of over $15.8 billion and leading positions in sales of gastrointestinal, oncology, anaesthesia including pain management, cardiovascular, central nervous system (CNS) and respiratory products. AstraZeneca has more than 40 years’ experience in cardiovascular medicine and aims to increase lifespan and improve quality of life by reducing the risk, prevalence and impact of cardiovascular disease. AstraZeneca has a comprehensive cardiovascular portfolio including Atacand®, Zestril®, Seloken ZOK® / Toprol XL™ and Plendil®. This heritage is complemented by an innovative pipeline including CRESTOR™, a new treatment for dyslipidaemia, the first oral direct thrombin inhibitor, Exanta®, and a novel treatment for type 2 diabetes / insulin resistance (AZ 242).
For further information please contact:
Jonathan Wilson
Ketchum
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Rina Amin
Ketchum
Tel: +44 20 7611 3513
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Julia Walker
AstraZeneca
Tel: +44 1625 510 866
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References:
1. McMurray J, Dietz R, Eichhorn E, et al. Practical recommendations for the use of ACE inhibitors, beta-blockers and spironolactone in heart failure: putting guidelines into practice. Eur J Heart Fail, 2001; 3: 495-502.
2. Task Force for the Diagnosis and Treatment of Chronic Heart Failure. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J, 2001; 22: 1527-1560
3. Cleland JGF, Khand A, and Clark A. The heart failure epidemic: exactly how big is it? Eur Heart J, 2001; 22: 623-626.
4. Hedberg P, Lönnberg T, Jonason T et al. Left ventricular systolic dysfunction in 75-year-old men and women. A population-based study. Eur Heart J, 2001; 22: 676-683.
5. CONSENSUS Study Group. Effect of enalapril on mortality in severe congestive heart failure. N Engl J Med, 1987; 316: 1429-1235.
6. The Study of Left Ventricular Dysfunction (SOLVD) Investigators. Effects of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med,1991; 325: 293-302.
7. Packer M, Bristow MR, Cohn JN et al. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med, 1996; 334: 1349-1355.
8. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet, 1999; 359: 9-13.
9. Hjalmarson A, Goldstein S, Fagerberg B et al. Effect of metoprolol CR/XL in chronic heart failure: metoprolol CR/XL randomised intervention trial in congestive heart failure (MERIT-HF). Lancet, 1999; 353: 2001-2007.
10. Hjalmarson A, Goldstein S, Fagerberg B et al. Effects of controlled-release metopropol on total mortality, hospitalisations, and well-being in patients with heart failure (MERIT-HF). JAMA, 2000; 283: 1295-1302.
11. Packer M, Coats A, Fowler M et al. Effects of carvedilol on survival in severe chronic heart failure. N Engl J Med, 2001; 344: 1651-1658.
Journal
European Journal of Heart Failure