IS IT POSSIBLE TO REACH « OPTIMAL THERAPY » IN A SPECIALIZED HEART

FAILURE CLINIC?

Le Boyer A., Gurné O.

Cardiologie

Cliniques Universitaires St Luc – UCL

Bruxelles

PRACTICAL REALISATION AND ADVANTAGE OF HAVING A HEART FAILURE CLINIC

IN BELGIUM

HEART FAILURE CLINIC

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF CHRONIC HEART FAILURE - ESC 2005

An organized system of specialist heart failure care

- improves symptoms and reduces hospitalizationsClass of recommandation I, Level of evidence A

- improves mortalityClass of recommandation IIA, Level of evidence B

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF CHRONIC HEART FAILURE - ESC 2005

Various models have been tested (heart failure clinics, nurse-led home visits,and/or telephone follow-up, multidisciplinary care, extended home care services and telemonitoring,…)

It is not clear which model is superior

It is likely that the optimal model will depend on local circumstances and resources and whether the model is designed for specific sub-groups of patients

2006 200620032007 ?

THE PROBLEM (S)• PAST WAS NOT ALWAYS EASY (PRESENT ?)

– Relations between « cardiologists » within the same institution– Relations outside the hospital

• Cardiologists working in an hospital or outside• Cardiologist in the University or in Periphery• General practionners and (our) hospital and specialists

• PROBLEM OF BUDGET– Could be paradoxal « a priori » … but in Belgium… – « un investissement de départ »

THESE PROBLEMS ARE EXITING EVERYWHERE

THE PROBLEM (S)

• MIND TO BE CHANGED

– DOCTOR = THE ONE who knows (everything) and who does (everything)

– patient = the one who is taking the pills without asking any questions– Learn to work in a team – Individualism of the doctors– The patient can – should be an actor of his own health

THESE PROBLEMS ARE EXITING EVEYWHERE

Heart Failure Clinic - St Luc Hospital• Hospital based• Nurse led• Mainly taking in charge hospitalized patients in cardiology (EF < 35%)

– Education– Coordination

• MD (cardiologist, GP• Psychologist• Physiotherapist• Dietician• Nurses of the cardiology unit• Home care (AUXAD : logistical support at home)• Palliative care

– Registry– Follow-up of patients (phone calls ><)

Number of CHF patients inclusion

210

175192

154

183

0

50

100

150

200

250

2003 2004 2005 2006 2007extrapolé

Number of CHF patients phone calls

37

50

75

126140

0

20

40

60

80

100

120

140

2003 2004 2005 2006 2007extrapolé

INCLUSION• N = 543 patients

– Taken from a registry of 1033 patients Ejection fraction < 35%(5 oct 2007)

• Patients inclusion was made for this survey according to

– Follow-up available at 6 months (or death before) in all patients– No Cardiac surgery or PCI during the 6 first months of follow-up

Inclusion data obtained at the end of an hospitalization (for the treatment)

Comparison between follow-up • By a specialized structure n = 163• By another structure (± control group) n = 380

FOLLOW-UP

specialized heart failure unit Control Group

• Incl/ 6m 163 380• 12 m 132 80.1 % 230 60.5%

ACE TREATMENT

89 85,6 87,2

0

20

40

60

80

100

INCLUSION 6 MONTHS 12 MONTHS

%

87,979,1 78,7

0

20

40

60

80

100

INCLUSION 6 MONTHS 12 MONTHS

Specialized CHF clinic Control Group

P=0.10 P=0.06

INH A II TREATMENT

10,413,1 13,6

0

20

40

INCLUSION 6 MONTHS 12 MONTHS

%

8,2

12,7 12,9

0

20

40

INCLUSION 6 MONTHS 12 MONTHS

Specialized CHF clinic Control group

ACE or AII INHIBITORS TREATMENT

96,9 96,1 96,8

0

20

40

60

80

100

INCLUSION 6 MONTHS 12 MONTHS

%

93,789,6 89,1

0

20

40

60

80

100

INCLUSION 6 MONTHS 12 MONTHS

Specialized CHF clinic Control group

P=0.02 P=0.02

BB TREATMENT

86,594,1 93,6

0

20

40

60

80

100

INCLUSION 6 MONTHS 12 MONTHS

%

76,8 80,7 82,7

0

20

40

60

80

100

INCLUSION 6 MONTHS 12 MONTHS

Specialized CHF clinic Control group

P=0.001 P=0.001

ACE /AII INHIBITORS and BB TREATMENT

85,390,8 92

0

20

40

60

80

100

INCLUSION 6 MONTHS 12 MONTHS

%

72,4 74,7 75,7

0

20

40

60

80

100

INCLUSION 6 MONTHS 12 MONTHS

Specialized CHF clinic Control group

P=0.001 P=0.001

SPIRONOLACTONE TREATMENT

69,9 68,6 65,6

0

20

40

60

80

100

INCLUSION 6 MONTHS 12 MONTHS

%

67,6

5649

0

20

40

60

80

100

INCLUSION 6 MONTHS 12 MONTHS

Specialized CHF clinic Control group

P=0.004P=0.01

ACE /AII INHIBITORS and BB and Spironolactone TREATMENT

56,564,7 62,4

0

20

40

60

80

100

INCLUSION 6 MONTHS 12 MONTHS

%

50,544

39,6

0

20

40

60

80

100

INCLUSION 6 MONTHS 12 MONTHS

Specialized CHF clinic Control group

P=0.001P=0.001

0

20

40

60

80

100

baseline 6 months 12 months

lisinoprilperindoprilramipiril

0

20

40

60

80

100

baseline 6 months 12 months

lisinoprilperindoprilramipiril

Relative ACE INH mean daily dose (in % « max dose »

Specialized CHF follow-up Control group

4,14,6 4,6

0

2,5

5

7,5

10

INCLUSION 6 MONTHS 12 MONTHS

10,2

25,328,1

0

12,5

25

37,5

50

INCLUSION 6 MONTHS 12 MONTHS

3,4

5,1

6,3

0

2,5

5

7,5

10

INCLUSION 6 MONTHS 12 MONTHS

14 16,119,1

0

12,5

25

37,5

50

INCLUSION 6 MONTHS 12 MONTHS

Beta Blockers mean daily dose

bisoprolol carvedilol

bisoprolol carvedilol

Specialized CHF clinic

Control group

0

20

40

60

80

100

baseline 6 months 12 months

carvedilol

bisoprolol

0

20

40

60

80

100

baseline 6 months 12 months

carvedilol

bisoprolol

Relative BB mean daily dose (in % « max dose »

Specialized CHF follow-up Control group

14,1

9,1

0

10

20

30

40

6 months 12 months

%

26,8

20

0

10

20

30

40

6 months 12 months

%Specialized CHF clinic Control group

Combined death or CHF hospitalization events

P=0.001

P=0.01

CONCLUSION

• In a relatively unselected population, it is posible to reach a high percentage of patients treated by an ACE Inh or an Inh A II AND a Beta Blocker

• Higher use of Spironolactone was also achieved

• The dosage of these compounds can also be simultaneously more increased, even if the target doses described in the large randomised studies performed were not achieved

CONCLUSION

• This approach translate in a better prognosis for these patients

• It could explained - partially - the results obtained in « Heart Failure Clinics »

• Others factors, such as education and possibility to maintain a closer contact (telephone, consultation) with the patients, play certainly also an important role

ALDACTONEEPLERENONE

ACEIARB