107 Care management of heart failure in elderly patients in France. Results from the DEVENIR study

RationaleThe part of elderly patients (pts) in heart failure (HF) population is growing. They might pose specific problems due to the greater proportion of HF with preserved LVEF, more frequent comorbidities or contra-indications to recommended HF treatment.Objectivesto describe the care management of pts > 80-year treated for HF in France.MethodsCross sectional observational survey with retrospective collection of data at hospital discharge. Pts must have been diagnosed with CHF and have been hospitalised for CHF within the previous 18 months. Pts are classified according to the LVEF at hospital discharge.Results412 French outhospital cardiologists entered 1 452 pts meeting the inclusion criteria. FEVG at hospital discharge was known for 1408 pts. 355 (25%) were more than 80-year-old. Management care at hospital discharge according to age and LVEF is detailed below.LVEF < 40%LVEF 40-50%LVEF > 50%TotalAge>80ACEI/ARB84%81%80%82%*BB71%67%40%†,‡62%*Loop diuretics92%85%85%88%Spironolactone/eplerenone26%20%18%22%*Digoxin20%15%29%21%*Calcium antagonists10%14%37%†,‡18%Anticoagulants49%45%51%49%*Age≤80ACEI/ARB93%93%85%†,‡92%BB79%78%76%79%Loop diuretics90%82%79%†,§86%Spironolactone/eplerenone35%21%25%†,§30%Digoxin16%15%16%15%Calcium antagonists9%19%21%†,§13%Anticoagulants42%39%39%41%†p<0.05 for comparisons between LVEF > 50% and LVEF<40%;‡p<0.05 for comparisons between LVEF>50% and LVEF between 40% and 50%;§: p<0.05 for comparisons between LVEF<40% and LVEF between 40% and 50%;*p<0.05 for comparisons between > 80 and ≤ 80 years old adjusted for LVEF.ConclusionBB, ACEI/ARB, spironolactone/eplerenone are less often prescribed in elderly patients contrasting with digoxin and anticoagulants prescription. These differences persist after adjustment on LVEF

064 Temporal trends in prescription rates of recommended treatments in chronic heart failure outpatients: a comparison of three French surveys IMPACT RECO I, II & III

BackgroundRecent registries have shown that recommended drugs for the treatment of congestive heart failure (CHF) remain under-prescribed in daily practice.AimsTo compare prescription rates of CHF drugs in three French surveys Impact Reco I, II and III.MethodsWe included outpatients followed by private cardiologists: 1947 in Impact Reco I (2005), 1974 in Impact Reco II (2005/2006) and 1574 in Impact Reco III (2007), with NYHA class II-IV heart failure and a left ventricular ejection fraction < 40%, and we compared treatment modalities. Recommended treatments and target doses were defined according to ESC guidelines.ResultsThere was an improvement in both the rate of prescription, and in the proportion of patients reaching target dose or 50% of target dose of ACE I, ARBs and beta blockers (see table).ConclusionWe observed an improvement with time in the management of CHF outpatients with an increase in prescription rates of recommended CHF drugs, as well as in the dosage used for ACE-I, ARB and beta-blockers,PrescriptionIMPACT I 2005IMPACT II 2005/2006IMPACT III 2007Global population191719741574ACE INumber patients with prescriptionN (%)1361 (71.0)1349 (68.3)1099 (70.2)Target dose%48.757.3*52.3•50% Target dose%80.484.5*88.4†,•ARBsNumber patients with prescriptionN (%)395 (20.6)592 (30.0)*516 (33.3)†,•Target dose%9.17.420.7†,•50% Target dose%52.949.768.6†,•BetablockersNumber patients with prescriptionN (%)1245 (65.2)1382 (70.0)*1229 (78.3)†,•Target dose%18.423.4*25.7†50% Target dose%47.353.5*59.9†•*: p<0.05 Impact II vs I•: p<0.05 Impact III vs II†: p<0.05 Impact III vs Ialthough there is still room for improvement particularly for beta blockers. These encouraging findings suggest a better awareness and implementation of ESC guidelines by French private cardiologists

088 Prescription of beta blockers at hospital discharge and beyond, in patients with heart failure. Results from the DEVENIR study

RationaleBeta blockers are a corner stone treatment of heart failure (HF) in patients with altered systolic function (LVEF<40%). Guidelines are less clear for HF patients with preserved systolic function (LVEF>50%) or for patients belonging to the “grey zone” (LVEF 40-50%).Objectivesto describe the prescription rate of beta-blockers in HF patients.MethodsCross sectional observational survey with retrospective collection of data at hospital discharge. Patients must have been diagnosed with CHF and have been hospitalised for CHF within the previous 18 months. Patients are classified according to the LVEF at hospital discharge.Results1 452 patients were included by 412 French outhospital cardiologists. 1137 with known LVEF at hospital discharge have had at least one visit by the cardiologist between hospital discharge (mean delay 5.76±4.51 months). In a multivariate model, BB prescription was more frequent in HF from ischemic origin (OR=1.39) or with dilated cardiomyopathy (OR=1.44) and less frequent in older patients (OR=0.97 per year) and in case of asthma/COPD (OR=0.31 and if FEVG was >50% (OR=0.62).LVEF < 40% N=661LVEF 40-50% N=282LVEF > 50% N=194Total N=1137At hospital discharge/at entry in the surveyBB78%/83%78%/85%62%/70%76%/82%Recommended BB†75%/77%72%/74%54%/62%71%/74%Reaching the target dose8%/16%7%/16%7%/13%7%/15%Changes since dischargeBB added*28%34%25%28%BB stopped**1%1%2%1%BB dose increased*27%27%17%25%BB dose decreased4%1%3%3%†metoprolol, nebivolol, bisoprolol, carvedilol ;*percentage calculated in patients without BB at hospital discharge (N=278);**percentage calculated in patients with BB at hospital discharge (N=859).ConclusionRate of betablockers prescription is high at hospital discharge. Outhospital cardiologists not only pursue but also amplify the care strategies defined during hospitalisation increasing the proportion of patients receiving BB and the percentage reaching the target dose

082 Chronic obstructive pulmonary disease: the new deal for b-blocker prescription in chronic heart failure

BackgroundThe recent European Guidelines for the treatment of CHF 2008 underlined that the majority of patient with CHF and COPD can safely tolerate β-blocker therapy.AimsThe IMPACT-RECO program III analysed the impact of NYHA class and of comorbidities on therapeutic management of French outpatients with stable CHF and left ventricular ejection fraction (LVEF) < 40%.MethodsThis survey was carried out from March 2007 to December 2007 among randomly selected French private cardiologists. 1574 patients with CHF and LVEF < 40% were included. Key demographics including comorbidities such as asthma and COPD, as well as ongoing medical treatment of CHF were collected. Physicians were asked about reasons for not prescribing β-blockers.ResultsMean age was 71±11 years, 75% of the patients were men, 34% were in NYHA class III-IV, 54% had coronary artery disease, 30% atrial fibrillation and the mean LVEF was 34±7%. 78.3% of the patients received a β-blocker, and asthma or BPCO were reported in 13.7%. 341 patients were not receiving β-blockers. The first reason for non-prescription was presumed contra-indication in 51.9% (177 pts). This contra-indication was asthma or COPD in 71%, symptomatic hypotension in 15%, bradycardia in 12% and other problems in 8%. The second reason for non prescribing β-blockers was previous side effects in 35.2% (120 pts) including heart failure decompensation in 39%, symptomatic hypotension in 36%, asthenia in 26%, bradycardia in 18%, impotence in 5% and others in 6%. Lastly, in 10.9% of patients without β-blockers, the reason for non prescription was fear of potential side effect.ConclusionRespiratory disease remains the main reason for not prescribing β-blockers in CHF despite the fact that selective β-blockers are now recommended in this population. Room remains for improvement in β-blockers prescription rate in CHF patients with concomitant COPD, underscoring the importance of pursuing education of cardiologists

100 Renal dysfunction and use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in chronic heart failure

BackgroundEuropean Guidelines for the treatment of CHF 2008 underline that there is no absolute level of creatinine which precludes the use of angiotensin converting enzyme inhibitors (ACE-Is) or angiotensin receptor blocker (ARBs).AimsThe IMPACT-RECO program III analysed the impact of NYHA class and of comorbidities on therapeutic management of French outpatients with stable CHF and low left ventricular ejection fraction (LVEF).MethodsThis survey was carried on 2007 among randomly selected French private cardiologists. 1574 patients with CHF and LVEF < 40% were included.ResultsMean age was 71 ± 11 years, 75% of the patients were men, 34% were in NYHA class III-IV, 54% had coronary artery diseases, 30% had atrial fibrillation and the mean LVEF was 34 ± 7%. Creatinine value was recorded in 1332 patients. Mean creatinine concentration was 119 ± 50 μmol/L and mean creatinine clearance was 59.6 ± 26.8 ml/kg/min. Renal dysfunction defined by creatinine concentration > 220 μmol/L or 25 mg/dL was found in 173 patients. In the 467 patients not receiving ACEIs, reasons for non prescription were firstly contra-indication in 69 patients (14.8%) mostly because of renal dysfunction in 54 patients (78.3%), secondly side effects in 365 patients (78.2%) with renal insufficiency found in 25 patients (6.85%). In 1033 patients, ARBs was also not prescribed because of contra-indication for renal dysfunction in 79 patients (90.8%), or intolerance with renal insufficiency in 40 patients (32.8%). Thus, despite a mean creatinine clearance of 33.3 ± 15.1 mL/kg/min in 173 patients with renal dysfunction, ACEIs/ARB were not prescribed in 133 patients considering renal dysfunction as a contra-indication.ConclusionRenal dysfunction remains the main reason for not prescribing ACEIs/ARBs in CHF despite the possibility to easily adapt their dose to creatinine clearance. Improvement is still necessary so that ACEIs/ARBs should not be denied to CHF patients with concomitant renal dysfunction