Potential Impact of Optimal Implementation of Evidence-Based Heart Failure Therapies on Mortality

Study Questions:

Does utilization of six therapies including angiotensin-converting enzyme inhibitor/angiotensin-receptor antagonist, beta-blockers, aldosterone receptor blockers, hydralazine/nitrate combinations, cardiac resynchronization therapy, and implantable cardioverter-defibrillators impact mortality of patients with systolic heart failure (HF) in a “real-world setting”?


The study investigators obtained eligibility criteria for each evidence-based HF therapy, the estimated frequency of use/nonuse of specific treatments, the case fatality rates, and the risk reductions due to treatment from multiple published sources, including registries and studies of HF quality care. The study investigators determined the number of deaths prevented or postponed because of each guideline-recommended therapy and overall.


They found that among patients with HF with reduced left ventricular ejection fraction in the United States (n = 2,644,800), the number eligible but not currently treated ranged from 139,749 for hydralazine/isorbide dinitrate to 852,512 for implantable cardioverter-defibrillators. The comparative number of deaths that could potentially be prevented per year with optimal implementation of angiotensin-converting enzyme inhibitor/angiotensin-receptor antagonist is 6,516; beta-blockers, 12,922; aldosterone antagonists, 21,407; hydralazine/isorbide dinitrate, 6,655; cardiac resynchronization therapy, 8,317; and implantable cardioverter-defibrillators, 12,179. If these treatment benefits were additive, optimal implementation of all six therapies could potentially prevent 67,996 deaths a year.


The investigators concluded that a substantial number of HF deaths in this country could potentially be prevented by optimal implementation of evidence-based therapies. These data may underscore the importance of performance improvement efforts to translate evidence-based therapy to routine clinical practice so as to reduce contemporary HF mortality.


This study suggests that there is opportunity to reduce mortality substantially by adhering to the six therapies that have been shown to reduce mortality in HF in randomized clinical trials. However, more recently, it has been argued that the therapy should be cost-effective, particularly with the utilization of cardiac resynchronization therapy and implantable cardioverter-defibrillators (Heart Fail Clin 2011;2:xiii-xviii.). The data from this study suggest that utilizing the less expensive therapies such as angiotensin-converting enzyme inhibitor/angiotensin-receptor antagonist, beta-blockers, aldosterone receptor blockers, hydralazine/nitrate combinations can reduce over 50,000 deaths per year in the United States, making it imperative that every patient with systolic HF should be considered for these therapies.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure

Keywords: Ventricular Function, Left, Receptors, Mineralocorticoid, Risk Reduction Behavior, Mineralocorticoid Receptor Antagonists, Heart Failure, Defibrillators, Implantable, United States, Cardiac Resynchronization Therapy

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