Improvement in the management of chronic heart failure since the publication of the updated guidelines of the European Society of Cardiology. The Impact-Reco Programme.

AIMS: Recent studies have shown that prescription rates and doses of recommended drugs for chronic heart failure (CHF) are not optimal in daily practice. The aim of the Impact-Reco programme was to analyse prescription rates of CHF drugs in stable outpatients with CHF related to left ventricular (LV) systolic dysfunction in two similar surveys in France. METHODS AND RESULTS: The two surveys, which included 1917 and 1974 patients, were performed between September 2004 to March 2005 and September 2005 to May 2006, respectively. Prescription rates of angiotensin-converting enzyme-inhibitors (ACE-I) remained stable (71 vs. 68%, respectively), whereas the proportion of patients receiving angiotensin receptor blockers (21 vs. 30%, P < 0.0001) and beta-blockers (65 vs. 70% P < 0.0001) increased significantly. Doses of ACE-I and beta-blockers increased significantly between the two surveys. However, the improvement was of lesser magnitude in some subgroups of patients, such as elderly patients or patients with renal failure. CONCLUSION: The Impact-Reco programme found an improvement in prescription rates and in the dosage of neurohumoral antagonists in French outpatients with stable CHF. However, there is still room for improvement, especially regarding the doses of medications and the treatment of some subgroups of patients such as the elderly and patients with renal failure.

An education program for risk factor management after an acute coronary syndrome: a randomized clinical trial.

IMPORTANCE: Lifestyle improvements after an acute coronary syndrome reduce cardiovascular risk but are difficult to achieve. OBJECTIVE: To determine whether a nurse-led or dietician-led cardiovascular risk factor education program would improve risk factor reduction over the long term after an acute coronary syndrome. DESIGN, SETTING, AND PARTICIPANTS: The Réseau Insuffisance Cardiaque (RESICARD) PREVENTION: study was a 2-arm, parallel-group, multicenter, randomized clinical trial at 6 tertiary care hospitals in France. Patients hospitalized in a cardiac intensive care unit for an acute coronary syndrome with at least 1 lifestyle risk factor (current smoking, sedentary lifestyle, or overweight or obesity) were randomized according to a computer-generated list with sequentially numbered, sealed envelopes. INTERVENTION: Patients underwent an education program in a unique non-hospital setting (a House of Education) or were treated according to physicians' usual standard of care. MAIN OUTCOMES AND MEASURES: The primary outcome was a composite that included at least 1 of the following: smoking cessation, at least 3 hours per week of physical activity, at least 5% reduction in weight, and at least 4% reduction in waist circumference. Patients were followed up for 1 year. An intent-to-treat analysis was performed. RESULTS From June 21, 2006, to July 30, 2008, a total of 251 patients were randomized to the House of Education and 251 to conventional care. The 2 groups did not differ significantly at 12 months in the primary composite outcome (51.8% vs 49.8% success rate; adjusted relative risk [aRR], 1.11; 95% CI, 0.90-1.37) or with correction of all risk factors (aRR, 1.22; 95% CI, 0.89-1.66). Similarly, the 2 groups did not differ by physical activity (aRR, 1.05; 95% CI, 0.92-1.21), smoking cessation (aRR, 0.99; 95% CI, 0.87-1.13), and weight or waist reduction (aRR, 1.07; 95% CI, 0.84-1.36). CONCLUSIONS AND RELEVANCE: Compared with conventional care, the House of Education did not result in superior improvement in lifestyle-related cardiovascular risk factors after an acute coronary syndrome. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00337480.

Optimization of heart FailUre medical Treatment after hospital discharge according to left ventricUlaR Ejection fraction: the FUTURE survey.

BACKGROUND: No clinical practice guidelines are available for the treatment of heart failure (HF) in patients with preserved left ventricular ejection fraction (LVEF). AIMS: To determine how cardiologists manage medical treatment in HF patients after hospital discharge, according to LVEF. METHODS: The FUTURE study was a cross-sectional survey conducted in HF outpatients by French private cardiologists between September 2007 and August 2008. Patients had to have been hospitalized within the previous 18 months with a diagnosis of HF. Clinical data and HF treatments (angiotensin-converting enzyme inhibitors [ACEIs], angiotensin receptor blockers [ARBs], beta-blockers, diuretics and aldosterone antagonists) were recorded retrospectively, with precise information on drug doses, at two successive time points (at hospital discharge and at the index consultation). HF treatment was compared in patients with reduced (less than or equal to 40%) versus preserved (more than 40%) LVEF. RESULTS: Completed data were available for 1137 HF patients enrolled by 424 cardiologists. Mean patient age was 72±11 years; LVEF was reduced in 56% and preserved in 44%. The therapeutic approach was similar in the two groups, both at hospital discharge and at the index consultation. At the index consultation, HF treatment was: beta-blocker (74%); ACEI/ARB (83%); loop diuretic (86%); aldosterone antagonist (31%). The majority of patients (62%) received a beta-blocker plus an ACEI or an ARB; 56% reached more than or equal to 50% of the target dose for each treatment. There were no major differences in treatments and dosages between the groups with low and preserved LVEF. In 15% of cases where the drug dose was not increased, fear of adverse events was reported as the reason. CONCLUSION: The FUTURE survey showed a similar approach to HF treatment irrespective of LVEF. Compared with previous studies, we saw an improvement in the use of recommended HF drugs, especially beta-blockers. However, achievement of target doses could be improved.

RESICARD: East Paris network for the management of heart failure: absence of effect on mortality and rehospitalization in patients with severe heart failure admitted following severe decompensation.

BACKGROUND: Heart failure presents a major public health problem due to its high prevalence and the increasing number of hospital admissions for this condition. A coordinated healthcare network involving general practitioners and cardiologists was set up in the east of Paris in an effort to improve the management and outcomes of patients with severe heart failure. AIMS: To reinforce patient education, improve compliance with medications and identify symptoms requiring treatment modification. METHODS: In this 'before and after' study, the control group comprised patients hospitalized for severe heart failure who received conventional management in the year preceding the network set-up. The comparative group consisted of patients hospitalized for severe heart failure who underwent network-led care. RESULTS: No significant differences were found between rates of first rehospitalization and all-cause mortality at 1 year between control and network groups, or between rates of first hospitalization due to cardiac causes, time to the first event, duration of hospitalization, rates of cardiac death or time to death. CONCLUSIONS: In this non-randomized study, we found no benefit from management according to the RESICARD healthcare network in terms of mortality or hospitalization in patients with severe chronic heart failure.