Brussels, 13 May 2005
Heart failure patients who are treated in accordance with established European guidelines recover better than patients who are not, yet many doctors still fail to adhere to the guidelines and prefer to rely on their own impression of what might be best, report two new studies.
The MALHER study (medical management of chronic heart failure in Europe) is the largest-ever European study to look into the effect of prescribing practices on the outcome for heart failure patients outside of a clinical trial. The study looked at the way 1,410 patients with mild to moderate heart failure were treated in six European countries (France, Germany, Italy, the Netherlands, Spain and the UK). The patients, whose progress was followed for six months, were aged 40 or over, and had an average age of 69.
The researchers examined how closely the patients' treatment adhered to the guidelines issued by the European Society of Cardiology (ESC) in relation to the use of the five most commonly used cardiac drugs: ACE-inhibitors, beta-blockers, spironolactone, diuretics and cardiac glycosides.
'We found that where doctors had treated their patients in accordance with the ESC guidelines, fewer patients had to be referred to the hospital due to deterioration of their heart failure or for cardiovascular symptoms, and there was a longer time before patients had to be readmitted to hospital because of their symptoms,' said Michel Komajda, professor of cardiology at the Pitie-Salpetriere Hospital in Paris and the main author of the report.
'However, the study showed that only 60 per cent of patients were treated according to the ESC guidelines with ACE-inhibitors2, beta-blockers or spironolactone3 - the three cardiac drugs for which there is the strongest evidence of benefit - and only 63 per cent of patients were treated according to the guidelines for these three drugs plus the two other commonly used drugs, cardiac glycosides and diuretics. This means there is a high proportion of patients who are not receiving the best possible treatment for their condition, and who suffer worsening symptoms and even death as a result,' he added.
According to Professor Komajda, there is plenty of room for improvement in the treatment of patients with heart failure and training programmes to improve the quality of care for cardiac patients should be developed.
It is hoped that the result of the MALHER study will encourage cardiologists to adhere to treatment guidelines. Indeed, a related study has underlined the difficulty of persuading doctors to follow guidelines for treatment rather than relying on their own impressions of what might be best. In some cases, patients who are most in need of the best treatment receive the worst, state the authors.
'It is obvious that guidelines improve outcome, so it is hard to understand why they are adopted so poorly. Surveys have shown that a limited number of doctors actually know about the existence of the guidelines, and even when they do know, they do not necessarily put them into medical practice. Sometimes physicians feel they are flooded by too much information and a plethora of guidelines,' explains Jean-Pierre Bassand, head of the department of cardiology at the University Hospital Jean Minjoz in Besançon, France.
Reasons why doctors do not follow guidelines include economic constraints, lack of belief in the guidelines and 'nihilism', believes Professor Bassand.
'This means that treatments with life-saving potential are under-prescribed for a wide variety of reasons, valid or otherwise,' he says.
Professor Bassand therefore calls on guidelines issued by professional organisations such as the ESC to be considered as pivotal educational tools that should be used in continuing medical education programmes, which all doctors should attend so that they can update and extend their knowledge.
'Otherwise, many patients will continue to suffer unnecessarily,' he concluded.
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