Compliance by Referring Physicians With Recommendations on Heart Failure Therapy from a Tertiary Center

Background: We tested the assumption that general practitioners do not use medication as recommended and do not follow recommendations made by heart failure specialists.

Methods: The study included 193 stable patients referred to and subsequently seen at our heart failure clinic between 1995 and 2001 with an ejection fraction of 40% or less. They had 1906 visits (1661 with structured follow-up). Recommendations by heart failure specialists regarding medication influencing prognosis and adherence of referring physicians to them were recorded.

Results: Ninety-six percent of patients were taking angiotensin-converting enzyme (ACE) inhibitor/angiotensin-II receptor blocker (ARB) when referred. The prescription rate of β-blockers and spironolactone increased after publication of large trials (more than 80% in 2001). Doses were inappropriate for both ACE-inhibitors/ARBs (55% ± 30% of target dose) and β-blockers (29% ± 24%). Recommendations were followed closely for dose reduction/discontinuation of all drugs (82%) and start/uptitration of spironolactone (78%). Adherence was less (P < .01) for start/uptitration of ACE inhibitors/ARBs (62%) and β-blockers (48%). Recommendations regarding single-step start/uptitration were more successful (ACE-inhibitors/ARBs, 70%; β-blockers, 63%; single-step of both, 67%) than multiplestep uptitration (ACE inhibitors/ARBs, 48%; β-blocker, 38%; P < .001). This was particularly true if recommendations concerned multiple-step uptitration of both drugs (25%, P < .001). There was no difference between general practitioners and cardiologists.

Conclusions: Although penetration of drugs beneficial in heart failure was high upon referral, doses were lower than recommended, and recommendations regarding changes were insufficiently adhered to by the referring physicians. Simple, one-step recommendations were better implemented and may be combined with direct prescriptions during control visits to guarantee adequate medical therapy.