Cardiac Device Therapy in Heart Failure: Between Guidelines and Current Practice. Where Are We?

Abstract

Background: Over last few decades, treatment of heart failure witnessed a leap especially regarding device therapy which decreases heart failure burden and mortality, however; in heart failure with reduced ejection fraction introduction of device therapy should be considered after maximizing guideline directed medical therapy. There is limited data from emerging countries regarding adherence to guidelines in heart failure management. Accordingly, this study sought to investigate adherence of cardiologists to optimization of guideline directed medical therapy prior to device implantation in patients with heart failure and reduced ejection fraction. Patients and methods: This study enrolled patients with heart failure and reduced ejection fraction who were admitted for cardiac device implantation (implantable cardioverter defibrillator or cardiac resynchronization therapy), patients’ data were collected; including demographic characteristics, baseline medications and doses were recorded as well as type of implanted device and its indication. Results: Thirty-one patients recruited in study, 25.8% were females. Mean age was 57.1±11.6 years, beta blockers were used in 83.9%, angiotensin converting enzyme inhibitor / angiotensin receptor blockers were used in 38.7%. Mineralocorticoid receptor antagonists were used in 67.74%. Treatment was initiated or up-titrated in less than two months prior to device implantation in 73.68% of primary indication cases. Three patients (9.67%) had implantable cardioverter defibrillator despite fulfilling the indications for cardiac resynchronization therapy (left bundle branch block or complete heart block). Among patients with primary indications; the decision of implantation was compatible with guidelines in 9.67% in form of following guideline directed medical therapy with up-titration until achieving maximum tolerated evidence-based doses prior to device implantation. Conclusions: Current study cast a light on poor adherence to guideline directed medical therapy in patients with heart failure and reduced ejection prior to device implantation, every effort should be made to bridge this practice gap and achieve better patients’ outcomes, not mentioning reconciling with cost-effectiveness; the overlooked economic standpoint of healthcare policy.