İskemik Kalp Yetersizliği Hastalarında Klinik Kılavuz Önerilerine Uyumun Değerlendirilmesi

Year 2019, Volume: 22 Issue: 3, 177 - 181, 24.12.2019

Veysel Oktay

Abstract

Giriş: Kalp yetersizliği (KY) önemli bir sağlık sorunu olup artmış mortalite, morbidite ve sağlık harcamasıyla ilişkilidir. Bu çalışmada, KY hastalarında mortaliteyi azalttığı gösterilen ilaçların klinik pratikte hedef doza ulaşılma oranları ve bunu etkileyen faktörlerin araştırılması amaçlandı.

Hastalar ve Yöntem: Ocak 2017-Aralık 2018 tarihleri arasında ST segment yükselmeli miyokart enfarktüsü (STYME) tanısıyla pimer perkütan koroner girişim (PPKG) yapılan ve sol ventrikül ejeksiyon fraksiyonu (SVEF) < %40 olan 480 hasta çalışmaya dahil edildi. Hastaların taburculuk ve altıncı ay vizitlerinde 2016 Avrupa Kardiyoloji Derneği Kalp Yetersizliği Tedavi Kılavuzu önerileri doğrultusunda mortaliteyi azalttığı gösterilmiş olan anjiyotensin dönüştürücü enzim inhibitörü (ACEI), anjiyotensin reseptör blokeri (ARB), betabloker (BB) ve mineralokortikoid reseptör blokeri (MRA) kullanım ve hedef doza ulaşma oranları araştırıldı.

Bulgular: Taburculuk esnasında ACEI/ARB, BB ve MRA reçete edilme oranları sırasıyla %86, %89 ve %28 idi. Altıncı ay takip vizitinde hastaların ACEI-ARB, BB ve MRA kullanım oranları sırasıyla %72, %78 ve %42 olarak saptandı. Altıncı ayda ACEI/ARB, BB ve MRA için hedef doza ulaşılma oranları sırasıyla %28, %22 ve %24’tü. Renal fonksiyonlarda bozulma, hiperkalemi ve bradikardi hedef doza ulaşmada en çok karşılaşılan önleyici nedenler oldukları tespit edildi.

Sonuç: KY hastalarında mortaliteyi azalttığı gösterilen ilaçların kullanımı ve hedef doza ulaşılma oranları istenilen düzeyin oldukça altındadır.

Keywords

Kalp yetersizliği, kılavuzlar, ilaç uyumu

Experiences of a University Hospital on Adhering to ESC Guidelines in Patients with Chronic Ischaemic Heart Failure

Abstract

Introduction: Ischaemic heart failure (HF) is a common public health problem that is associated with increased mortality, morbidity and medical costs. This study aimed to investigate the percentage of patients with HF who are taking target doses of the drugs to improve the mortality rate and assess the reasons for the patients’ non-adherence to treatment guidelines during the follow-up period.

Patients and Methods: Between January 2017 and December 2018, 480 patients who had been diagnosed with ST elevation myocardial infarction (STEMI) and had undergone primary percutaneous coronary intervention with a left ventricular ejection fraction (LVEF) of < 40% were enrolled in this study at our centre. The percentage of patients taking target doses of drugs that improved the mortality rate according to the 2016 European Society of Cardiology Guidelines for the treatment of HF, such as beta blockers (BB), angiotensin converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB) and mineralocorticoid receptor antagonists (MRA) at the time of discharge and at the 6-month follow-up period was investigated.

Results: Of the 480 patients, the follow-up data of 430 patients were available and the percentages of patients prescribed with ACEI/ARB, BB and MRA at discharge were 86%, 89% and 28%, respectively. At the 6-month follow-up, the percentages of patients using ACEI/ARB, BB and MRA were 72%, 78% and 42%. About 7% of patients using BB switched to a different BB and 5% of the patients using ACEI were found to switch to an ARB. The percentages of patients taking target doses of ACEI/ARB, BB and MRA were 28%, 22% and 24%, respectively. Metoprolol succinate, ramipril and spironolactone were the most prescribed agents. Worsening of renal function, hyperkalaemia and bradycardia were the main reasons for non-achievement of target doses during the follow-up period.

Conclusion: In clinical practice, the percentage of patients with ischaemic HF who were receiving optimal target doses of BB, ACEI and MRA was far below the desired levels as compared to the European Society of Cardiology (ESC) guidelines.

Keywords

Guidelines, heart failure, medication adherence

References

• 1. Tavazzi L, Senni M, Metra M, Gorini M, Cacciatore G, Chinaglia A, et al. Multicenter prospective observational study on acute and chronic heart failure: one-year follow-up results of IN-HF (Italian Network on Heart Failure) outcome registry. Circ Heart Fail 2013;6:473-81.
• 2. Hood SR, Giazzon GS, Lane KA, Wang J, Eckert GJ, Wanzhu T, et al. Association between medication adherence and the outcomes of heart failure. Pharmacotherapy 2018;38:539-45.
• 3. Granger BB. Self-reported medication adherence for heart failure is associated with lower risk of all-cause hospitalization and death. Evid Based Nurs 2015;18:123.
• 4. Chang LL, Xu H, Devore AD, Matsouaka RA, Yancy CW, Fonarow GC, et al. Timing of post discharge follow-up and medication adherence among patients with heart failure. J Am Heart Assoc 2018;7:e007998.
• 5. Konstam MA, Neaton JD, Dickstein K, Drexler H, Komajda M, Martinez MA, et al. Effects of high-dose versus low-dose losartan on clinical outcomes in patients with heart failure (HEAAL study): a randomised, double-blind trial. Lancet 2009;374:1840-8.
• 6. Maggioni AP, Dahlström U, Filippatos G, Chioncel O, Leiro MC, Drozdz J, et al. EURObservational Research Programme: the Heart Failure Pilot Survey (ESC-HF Pilot). Eur J Heart Fail 2010;12:1076-84.
• 7. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGH, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016;37:2129-200.
• 8. Leiro MGC, Cubero JS, Costello JG, Genis BA, Fernandez LS, Roig E, et al. Adherence to the ESC heart failure treatment guidelines in Spain: ESC heart failure long-term registry. Rev Esp Cardiol 2015;68:785-93.
• 9. Komajda M, Schöpe J, Wagenpfeil S, Tavazzi L, Böhm M, Panikowski P, et al. Physicians’ guideline adherence is associated with long-term heart failure mortality in outpatients with heart failure with reduced ejection fraction: the QUALIFY international registry. Eur J Heart Fail 2019;21(7):921-9.
• 10. Giezeman M, Arne M, Theander K. Adherence to guidelines in patients with chronic heart failure in primary healthcare. Scandinavian Journal of Primary Health Care 2017;35:336-43.
• 11. Ouwerkerk W, Voors AA, Anker SD, Cleland JG, Dickstein K, Flippatos G, et al. Determinants and clinical outcome of up titration of ACE-inhibitors and beta-blockers in patients with heartfailure: a prospective European study. Eur Heart J 2017;38:1883-90.
• 12. Lauren G, Stevenson LW, Small R, Parambi R, Hamershock R, Greenberg J, et al. Reasons for guideline nonadherence at heart failure discharge. J Am Heart Assoc 2018;7:e008789.
• 13. McDonagh TA, Blue L, Clark AL. European Society of Cardiology Heart Failure Association Standards for delivering heart failure care. Eur J Heart Fail 2011;13:235-41.
• 14. Mosterd A, Hoes AW. Clinical epidemiology of heart failure. Heart 2007;93:1137-46.