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Archives of cardiovascular diseases
Volume 105, n° 6-7
pages 355-365 (juin 2012)
Doi : 10.1016/j.acvd.2012.04.003
Received : 19 November 2011 ;  accepted : 19 April 2012
Optimization of heart FailUre medical Treatment after hospital discharge according to left ventricUlaR Ejection fraction: The FUTURE survey
Optimisation du traitement médical après hospitalisation pour insuffisance cardiaque selon la fraction d’éjection ventriculaire gauche : le registre FUTURE
 

Alain Cohen Solal a, b, c, , Irina Leurs d, Patrick Assyag e, Florence Beauvais c, Pierre Clerson f, Christine Contre d, Jean-François Thebaut g, Maxime Genoun h

in collaboration with the French National College of Cardiologists

a UMRS 942, Paris, France 
b Université Paris 7 Denis-Diderot, Paris, France 
c Service de cardiologie, hôpital Lariboisière, Assistance publique–Hôpitaux de Paris, 2, rue Ambroise-Paré, 75010 Paris, France 
d Laboratoire Menarini, Rungis, France 
e Service de cardiologie, hôpital Saint-Antoine, AP–HP, Paris, France 
f Service d’orgamétrie biostatistiques, Roubaix, France 
g Centre Alfred-Kastler, Sarcelles, France 
h Cabinet de cardiologie, Plan-de-Cuques, France 

Corresponding author. Service de cardiologie, hôpital Lariboisière, Assistance publique–Hôpitaux de Paris, 2, rue Ambroise-Paré, 75010 Paris, France. Fax: +33 1 49 95 84 39.
Summary
Background

No clinical practice guidelines are available for the treatment of heart failure (HF) in patients with preserved left ventricular ejection fraction (LVEF).

Aims

To determine how cardiologists manage medical treatment in HF patients after hospital discharge, according to LVEF.

Methods

The FUTURE study was a cross-sectional survey conducted in HF outpatients by French private cardiologists between September 2007 and August 2008. Patients had to have been hospitalized within the previous 18 months with a diagnosis of HF. Clinical data and HF treatments (angiotensin-converting enzyme inhibitors [ACEIs], angiotensin receptor blockers [ARBs], beta-blockers, diuretics and aldosterone antagonists) were recorded retrospectively, with precise information on drug doses, at two successive time points (at hospital discharge and at the index consultation). HF treatment was compared in patients with reduced (less than or equal to 40%) versus preserved (more than 40%) LVEF.

Results

Completed data were available for 1137 HF patients enrolled by 424 cardiologists. Mean patient age was 72±11 years; LVEF was reduced in 56% and preserved in 44%. The therapeutic approach was similar in the two groups, both at hospital discharge and at the index consultation. At the index consultation, HF treatment was: beta-blocker (74%); ACEI/ARB (83%); loop diuretic (86%); aldosterone antagonist (31%). The majority of patients (62%) received a beta-blocker plus an ACEI or an ARB; 56% reached more than or equal to 50% of the target dose for each treatment. There were no major differences in treatments and dosages between the groups with low and preserved LVEF. In 15% of cases where the drug dose was not increased, fear of adverse events was reported as the reason.

Conclusion

The FUTURE survey showed a similar approach to HF treatment irrespective of LVEF. Compared with previous studies, we saw an improvement in the use of recommended HF drugs, especially beta-blockers. However, achievement of target doses could be improved.

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Résumé
Buts

Il n’y a pas de recommandations scientifiques bien décrites auxquelles le cardiologue peut se référer en ce qui concerne le traitement de l’insuffisance cardiaque à fraction d’éjection préservée. Le but de cette étude a été de déterminer la façon dont les cardiologues prennent en charge le traitement médical des patients en fonction de leur FEVG après la sortie de l’hôpital.

Méthodes

FUTURE est un registre transversal réalisé sur des patients insuffisants cardiaques ambulatoires suivis par des cardiologues libéraux entre septembre 2007 et Août 2008. Les patients devaient avoir été hospitalisés au cours des 18 mois précédents, avec un diagnostic d’insuffisance cardiaque. Les données cliniques et le traitement médical (IEC, ARA2, bêtabloquants, diurétiques et antagonistes de l’aldostérone) ont été relevés à deux moments successifs (à la sortie de l’hôpital et à la consultation d’entrée dans l’étude) avec des informations précises sur les doses de médicaments.

Résultats

Des données complètes ont été obtenues chez 1137 patients insuffisants cardiaques par 424 cardiologues. L’âge moyen était de 72±11ans. La FEVG était abaissée (inférieure ou égale à 40 %) chez 56 % et préservée (supérieure à 40 %) chez 44 % des patients. À la sortie de l’hôpital aussi bien qu’à la consultation d’entrée dans l’étude, l’approche thérapeutique est apparue similaire dans les deux groupes. À la consultation d’entrée, le traitement était : bêtabloquants (74 %), IEC ou ARA2 (83 %), diurétique de l’anse (86 %) et antagonistes de l’aldostérone (31 %). La majorité des patients (62 %) recevait une combinaison de bêtabloquant et d’IEC ou ARA2 et 56 % avait atteint au moins 50 % de la dose cible pour chacun des traitements. Il n’y avait pas de différence majeure dans les traitements et dans les doses entre les deux groupes de patients avec FEVG basse ou préservée. Dans 15 % des cas où la dose de médicament n’a pas été augmentée, l’explication rapportée était une crainte des effets secondaires.

Conclusion

Quelle que soit la FEVG, FUTURE montre que l’approche du traitement de l’insuffisance cardiaque est similaire. Par rapport aux études antérieures, il est noté une amélioration dans l’utilisation des médicaments recommandés dans l’insuffisance cardiaque, en particulier les bêtabloquants. Toutefois, une amélioration est encore possible en ce qui concerne les doses administrées.

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Keywords : Heart failure, Epidemiology, Ejection fraction, Beta-blockers, ACE inhibitors

Mots clés : Insuffisance cardiaque, Épidémiologie, Fraction d’éjection, Bêtabloquants, IEC

Abbreviations : ACEI, ARB, COPD, ESC, HF, HFpEF, HFrEF, LVEF, NYHA


Background

HF is a costly public health problem that increases in prevalence with age in the populations of western countries [1]. Despite advances in medical strategies in the treatment of myocardial infarction or hypertension, the proportion of patients presenting with HF is increasing, with an estimated 500 to 750,000 HF patients in France [2], at least 10% of whom are elderly subjects (aged over 80 years). HF is a serious and potentially life-threatening disease that impairs quality of life. Median survival after diagnosis of HF does not exceed 4 years.

Although guidelines and recommendations for the treatment of chronic HF are based on clinical trial results [3], under “real-life” conditions, affected populations are often very different from patients enrolled in clinical trials [4]: they are generally older and more often have a preserved LVEF. The mean age of patients admitted to hospital for HF in France in 2000 was 77 years [5]. The “OFICA registry” [6], which records data on patients hospitalized for HF in France, shows that one-half of affected patients are aged over 80 years. In addition, a sizable number of hospitalized patients have preserved LVEF. The threshold used to define impaired and preserved LV function (35%, 40%, 45% or 50%) is not clearly defined. Nevertheless, the prognosis of HFpEF seems to be slightly better than that of HFrEF [7]. Whether treatment differs between patients with HFpEF and those with HFrEF remains unclear. The extent to which cardiologists continue and/or improve the treatment strategy initiated in hospital is unknown. It would also be interesting to know if cardiologists are more reluctant to optimize treatment in patients with HFpEF. These are some of the questions that the FUTURE survey set out to answer.

The primary objective of the FUTURE survey was to better describe the medical treatment of HF after hospital discharge, according to LVEF. Several studies of HF have been conducted previously in France (IMPROVEMENT [8], the National French Cardiologists survey [5], IMPACT-RECO 1 and 2 [9, 10] and the National General Hospitals registry [11]), showing increasing adherence to guidelines in current practice. However, none of these studies compared groups of HFrEF and HFpEF patients or analysed the prescriptions made at the time of hospital discharge and afterwards in HF outpatients.

Methods

The FUTURE study was a cross-sectional survey with retrospective data collection, conducted in HF outpatients by French cardiologists in private practice, between September 2007 and August 2008. Physicians were instructed to enroll the first four patients who satisfied the inclusion criteria. To fulfill these criteria, patients had to have been hospitalized within the previous 18 months with a diagnosis of worsening HF and not to be currently followed by the participating cardiologist. Patients who were participating in any other clinical trial during the study period were not authorized to participate in the survey. Neither age nor LVEF was an inclusion criterion.

Cardiologists were asked to list comorbidities, clinical features of HF at the time of the last hospitalization, the treatment prescribed at hospital discharge, the patient’s current clinical status and ongoing treatment. Clinical history and medical treatment(s) were recorded using the patient files from the cardiologists’ offices. Data concerning the last hospitalization for HF were collected retrospectively.

The CNIL (the French Commission on Data Processing, Data Files and Individual Liberties) gave its consent to the collection of patient data.

As the aim of the present study was to describe the influence of private cardiologists’ practice on treatment strategy, the analysis of treatments was restricted to HF outpatients who visited their cardiologist at least once since hospital discharge and before the date of baseline data collection (index consultation). Patients were divided into two groups (HFrEF and HFpEF) according to LVEF at hospital discharge (less than or equal to 40%, reduced LVEF; more than 40%, preserved LVEF). Treatment of HF (drug[s], dosage and target dose) was described according to the 2008 ESC guidelines for HF with reduced LVEF [3] (ACEIs [except for perindopril, which is not recommended for HF but was accepted because it is widely used in France at a target dose of 4mg/day] or ARBs, beta-blockers, loop diuretics and aldosterone antagonists, either alone or in combination).

Statistical analysis

Statistical analysis was performed with SAS 9.1 software (SAS Institute, Cary, NC, USA). Results are presented as means±standard deviations for continuous variables and as numbers and percentages for dichotomous variables. All tests were two-sided and the alpha risk was set at 0.05. The influence of demographic and clinical variables, as well as the characteristics of each cardiologist in terms of the probability of prescribing each therapeutic class, was modelled by logistic regression. The prevalence of HF with preserved LVEF was estimated with its two-sided 95% confidence interval, assuming a binomial distribution. Between-group comparisons were performed using an unpaired Student’s t test or the Mann–Whitney U test for continuous data and a Chi2 test or Fisher’s exact test for categorical variables. Some comparisons were adjusted for age using two-way analysis of variance.

Results

A total of 1673 patients with a diagnosis of HF established during a previous hospitalization were enrolled by 424 cardiologists between September 2007 and August 2008. Complete data were available for 1408 patients at hospital discharge; 221 patients were excluded from the analysis, mainly because they had not been hospitalized within the previous 18 months. LVEF at hospital discharge was not available for 44 patients. A total of 1137 patients attended at least one visit with their cardiologist between hospital discharge and the index consultation. Therefore, patient characteristics according to LVEF were described in 1408 patients, whereas the course and outcome of clinical variables and treatments were analysed on a subset of 1137 patients.

Patients were enrolled in the survey 5.8±4.5 months after hospital discharge after a mean number of 2.3±1.7 visits to the cardiologists. Average time between hospital discharge and the index consultation was less than 3 months for 403 patients, 3–6 months for 291 patients, 6–12 months for 286 patients and more than 12 months for 157 patients.

Characteristics and clinical variables at hospital discharge

For the 1408 patients analysed at hospital discharge, the mean age was 72±11 years, 65% were aged over 70 years, 67% were men and the mean LVEF was 40±13%. The cause of HF was ischaemic heart disease in 727 patients (52%), arterial hypertension in 582 (41%), valvular heart disease in 219 (16%), and was associated with primary dilated cardiomyopathy in 462 (33%) (more than one cause of HF could be reported in a given patient). Comorbidities were frequent and included hypertension (65%), diabetes (31%), renal failure (35%), asthma/COPD (18%) and anaemia (8%). Reasons for hospitalization were a first episode of acute HF (“de novo HF” according to the 2008 ESC classification [3]) in 44% of patients and worsening of known HF in 55%. In 33% of patients, the initial clinical presentation of HF on admission to hospital was acute pulmonary oedema. At hospital discharge, 69% patients had sinus rhythm as seen on their electrocardiogram.

LVEF was reduced (less than or equal to 40%) in 792 patients (56%) and preserved (more than 40%) in 616 (44%). Some characteristics (Table 1) were more frequent in HFpEF patients than in HFrEF patients: the former were older and more often were female, overweight or obese. HF had been diagnosed more recently and was more often of hypertensive or cardiac valvular origin and anaemia was more frequent. Conversely, plasma concentrations of B-type natriuretic peptide were significantly more elevated and renal failure was more frequent in patients with reduced LVEF. However, no difference was observed between the two groups regarding some comorbidities: ischaemic origin of HF, history of stroke, asthma/COPD and diabetes. Based on LVEF, the condition of HFpEF patients was less serious at hospital discharge (Table 2).

Change between hospital discharge and index consultation

Functional status was analysed in 1137 patients who visited the participating cardiologist between hospital discharge and the index consultation. At hospital discharge, most patients were in class II and III of the NYHA classification (58% in class II, 29% in class III, 7% in class I and 5% in class IV). At the index consultation, functional status was improved in all patients, regardless of ejection fraction (15% in NYHA class I, 63% in class II, 20% in class III, 2% in class IV; P <0.0001). Based on LVEF, the functional status of HFpEF patients remained significantly better (Table 2). In addition, systolic blood pressure was higher in HFpEF patients compared with in HFrEF patients (134±16mmHg and 124±17mmHg, respectively; P <0.0001). Heart rate was only available at the index consultation and was 72.7±16.3 beats/min and 72.6±15.8 beats/min in the HFrEF and HFpEF groups, respectively (difference not significant).

Therapeutic management
At hospital discharge

At the time of hospital discharge, 71% of 1137 patients were receiving one of the four recommended beta-blockers (carvedilol, bisoprolol, metoprolol CR XL or nebivolol), 82% were receiving an ACEI or an ARB, 87% were receiving a loop diuretic and 29% were receiving an aldosterone antagonist. Half of the patients (52.8%) received treatment combining a beta-blocker, an ACEI or an ARB and a diuretic. About one-third of patients (37%) treated with the combination of a beta-blocker and an ACEI or an ARB received more than or equal to 50% of the target dose for each treatment but only 5% of these patients were at the target dose. The target doses of HF treatment were seldom prescribed at hospital discharge, thus allowing cardiologists to titrate treatment further in the subsequent months. Other drugs were frequently prescribed: cardiac glycosides were given to 17% of patients, vitamin K antagonists to 43%, antiplatelet agents to 57%, statins to 60% and calcium channel blockers to 16%. Only 17% of patients were transferred to a convalescent ward or hospital and 83% returned home.

According to the LVEF, regardless of the HF treatment prescribed (ACEI and/or ARB, beta-blocker, loop diuretic or aldosterone antagonist), these therapies were prescribed significantly less frequently in HFpEF patients but the dose reached (more than or equal to 50% of target dose or target dose) was not different between the two groups, except for beta-blockers (Table 3). Differences were also found for non-drug therapies: a cardiac rehabilitation programme was initiated less often in HFpEF patients (13% vs 24%; P <0.0001); stays in a convalescent ward were less frequent in HFpEF patients (13% vs 19%; P =0.003); and specific educational information was given to fewer HFpEF patients (35% vs 48%; P <0.0001). Only a few patients (8%) joined an ambulatory health network combining private and hospital physicians (11% of HFrEF patients and 3% of HFrEF patients; P <0.0001).

At the index consultation

Treatment could have been modified by the cardiologist at least once since hospital discharge. All patients were treated (Figure 1): 74% with the recommended beta-blockers, 83% with an ACEI or an ARB, 86% with a loop diuretic and 31% with an aldosterone antagonist. The reasons for not prescribing beta-blockers were: contraindications to these agents (especially asthma/COPD) (35%); poor tolerance (21%); expectation of poor tolerance (10%); or beta-blockers considered as being useless (7%). The reasons for not prescribing an ACEI were dominated by: poor tolerance (occurrence of cough) (57%); contraindications (11%); expectation of poor tolerance (4%); or ACEIs considered as not being useful (8%). The main reason for prescription of an ARB was poor tolerance of an ACEI (70%). The majority of patients (62%) received treatment combining a beta-blocker with an ACEI or an ARB, and 54% received the three-drug combination with a loop diuretic. Concerning the dosage, 56% of patients treated with a beta-blocker plus an ACEI or an ARB received at least 50% of the target dose for each treatment and 15% of patients reached the recommended target doses. Other drugs were often prescribed: cardiac glycosides were given to 14% of patients, vitamin K antagonists to 42%, antiplatelet agents to 55%, statins to 60% and calcium channel blockers to 15%.



Figure 1


Figure 1. 

Treatments at index consultation according to left ventricular ejection fraction (LVEF) status (n =1137). ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker; indpt: independent of.

Zoom

According to the LVEF, as at hospital discharge, HFpEF patients received beta-blockers, ACEIs, loop diuretics or aldosterone antagonists significantly less frequently (Table 4). The proportions of patients who received a beta-blocker plus an ACEI or an ARB at target doses were similar in the two groups (16% in HFrEF patients and 15% in HFpEF patients). Beta-blockers were considered as not being useful in 12% of HFpEF patients vs 3% of HFrEF patients (11% vs 5% for ACEIs, respectively).

Change in treatment between hospital discharge and the index consultation

At the index consultation, HF medical treatment had been modified since hospital discharge. Some drugs were stopped and replaced due to adverse events or hypotension and others were added as the result of clinical impairment (Table 5, Table 6). A beta-blocker was added in 85 out of 332 patients not treated with beta-blockers at discharge and stopped in 49 out of 805 patients receiving beta-blockers at discharge, with a resultant positive balance of 36 patients (Figure 2). There was a positive balance of 21 patients for ACEIs or ARBs. The balance was negative for ACEIs and positive for ARBs: an ACEI was added in 46 out of 352 patients but stopped in 63 out of 785 and an ARB was added in 54 out of 970 patients and stopped in 16 out of 176. With the exception of patients in whom ACEIs were stopped, no difference in optimization of medical treatment after hospital discharge was found based on LVEF at hospital discharge, suggesting that the cardiologists’ therapeutic practices did not differ according to LVEF.



Figure 2


Figure 2. 

Change in beta-blocker treatment since hospital discharge according to left ventricular ejection fraction (LVEF) status (n =1137). BB: beta-blockers (metoprolol, nebivolol, bisoprolol, carvedilol). *Percentages based on number of patients without treatment at hospital discharge. **Percentages based on number of patients on treatment at hospital discharge.

Zoom

Cardiologists also increased the doses of drugs (Table 7, Table 8). There was a positive balance for all drugs. Among the 756 patients receiving a beta-blocker since hospital discharge until entry in the survey, doses were increased in 218 cases and decreased in 27, resulting in a positive balance of 191 patients (Figure 2). Among the 722 patients receiving an ACEI, doses were increased in 99 cases and decreased in 30 (positive balance of 69 patients). In the 151 patients treated with an ARB, the doses were increased in 23 cases and decreased in three (positive balance of 20 patients). No difference was found between HFrEF and HFpEF patients. The reasons for not having reached target dose were: satisfactory control with the current regimen (24% for beta-blockers, 26% for ACEIs, 27% for ARBs), ongoing current titration (32% for beta-blockers, 27% for ACEIs, 28% for ARBs), higher doses poorly tolerated (42% for beta-blockers, 40% for ACEIs, 38% for ARBs) or concern for possible adverse events with higher doses (16% for beta-blockers, 16% for ACEIs, 14% for ARBs). The number of patients who reached the target dose with combination therapy for HF (ACEI or ARB plus beta-blocker) was tripled compared with that at hospital discharge but remained low (15%). However, the majority of these patients (56%) received at least 50% of the target dose for each treatment.

There does not seem to be a major interaction between the time between hospital discharge and index consultation, and the treatment or dose of treatment at the index consultation (Table 5, Table 6, Table 7, Table 8). It seems that the addition of beta-blockers was increased in patients seen for the first time between 6 and 12 months, but our survey does not permit us to know if this introduction was made early or late after discharge.

Discussion

This survey on the management of HF with medical treatment by cardiologists in France is the first of its kind. Indeed, although the treatment of HFrEF patients is becoming increasingly better understood, the treatment of HFpEF patients is much less so. Drug treatment of HF should be based on the available guidelines. But the recommendations of the ESC regarding the treatment of HF were established primarily for patients [3]. Because of the limited evidence-based medicine on the optimal treatment of HFpEF, recommendations on the treatment of these patients to which the cardiologist may refer are much less precise. The purpose of this study was to determine how cardiologists in private practice manage HF patients after discharge from the hospital, taking into account LVEF.

The FUTURE survey has some original features compared with previous studies conducted in France. Unlike the IMPACT-RECO studies [9, 10], it included patients with HF regardless of LVEF. Moreover, the assessment of medical therapy was performed at two successive time points (at the time of hospital discharge and at the index consultation) and we have precise information on the doses of drugs.

Patient characteristics

Clinical data on HF patients at hospital discharge confirmed what has previously been reported, particularly with regard to HF (HF more often affects elderly subjects with frequent comorbidities) and more particularly with regard to HFpEF patients – a higher prevalence of elderly subjects and women in particular was found in this group. The shorter duration of the disease in the HFpEF patient group is probably attributable to the higher incidence of hypertension in this group. HF progresses more often by repeated brief episodes of acute HF decompensation (“transient HF” as defined in the 2008 ESC guidelines) than by chronic HF. This probably also explains the lower concentrations of B-type natriuretic peptide found at hospital discharge in this population. It is interesting to note the frequency of valvular heart disease (20%), arrhythmias (34%) and combined aetiologies (42%), which were higher in the HFpEF group than in the HFrEF group. In the context of clinical trials to evaluate a drug in HFpEF patients, a high percentage of these patients would not be eligible due to the usual inclusion or exclusion criteria used in HF trials [4] (elderly subjects, valvular heart disease, arrhythmia, etc.).

Therapeutic management in heart failure outpatients

The time between hospital discharge and inclusion in the survey is interesting to consider (i.e. about 6 months after discharge, patients paid two visits to their cardiologist on average). This can be considered very satisfactory (also taking into account the fact that the analysis was limited to patients who visited the cardiologist at least once since hospital discharge and that the inclusion period was 18 months). In contrast, only 28% of patients visited their cardiologist during the first 3 months. This may be considered as an unreasonable delay, as the majority of readmissions to hospital are known to occur within the first weeks after hospital discharge [12].

The findings of the FUTURE survey provide a representative snapshot of treatment of HF, with satisfactory management of patients and high rates of prescription of beta-blockers and ACEIs or ARBs. With regard to HFrEF, our data show a slight improvement compared with the IMPACT-RECO 1 and 2 studies [9, 10] carried out between 2004 and 2006. Concerning the use of beta-blockers, the rate of prescription increased and is now higher than that of ACEIs. However, it has peaked at 75–80%, reflecting perhaps a figure that is difficult to surpass. This is true primarily due to contraindications involving mainly the respiratory system and the risk of severe bradycardia in the elderly, and the lack of formal systematic indications for beta-blockers in HFpEF. Moreover, the prescription of beta-blockers and renin-angiotensin system antagonists was already high at the time of hospital discharge in our survey, leaving relatively little room for cardiologists to increase the number of prescriptions.

Data on the management of HFpEF patients have an original aspect in several respects. It can again be noted that most of the findings were recorded at the time of hospital discharge. There was a high rate of prescription of beta-blockers and ACEIs or ARBs, while recommendations regarding these drugs in this indication are not so broad as to justify these prescription rates [3]. The results seemed to indicate that the combination of a beta-blocker and an ACEI or an ARB was the rule once a diagnosis of HF was established, regardless of LVEF. However, evidence-based medicine regarding the efficacy of ACEIs or ARBs [13, 14, 15, 16] and beta-blockers [13, 17] on robust endpoints is lacking. Furthermore, our investigation targeted beta-blockers authorized in France in HF; if we also considered other widely used beta-blockers in France, such as atenolol or acebutolol, prescription rates for beta-blockers in HFpEF patients would be extremely high. Similarly, the rate of prescription of aldosterone antagonists, which were only indicated in NYHA classes III and IV systolic HF at the time of the survey, may appear illogical in these patients. However, in France, spironolactone has an indication for treatment of diuretic-induced hypokalaemia, whatever the cause, which could explain some of the prescriptions.

Doses of heart failure treatment

Our survey is the first in France carried out on the doses of drugs for HF at hospital discharge and in outpatient private practice. In HFrEF, we noted that the prescribed doses were relatively low with regard to beta-blockers and ACEIs. Although it is conceivable that, at the time of hospital discharge, the doses of beta-blockers prescribed were far from the target doses recommended by scientific societies, the explanation is less acceptable for ACEIs or ARBs. In contrast, at the inclusion visit, several months after hospital discharge and after at least two office visits, we would expect the prescription of higher doses of these drugs. Although the rate of prescription of the combination of beta-blockers and an ACEI or an ARB at recommended target doses tripled between hospital discharge and index consultation, less than 20% of HFrEF patients reached the recommended target dose for each treatment at a distance from hospital discharge. We may ask why the recommended target doses were not reached. In about 30% of cases, the absence of prescribing an increase was justified by reported intolerance to beta-blocker therapy but also simply out of concern for possible intolerance or that such therapy was not useful. It seems important to consider this concern about lack of usefulness or suspected intolerance to higher doses of these treatments, particularly beta-blockers. This is a real problem in everyday practice that is rarely acknowledged by physicians but needs to be overcome. The FUTURE study showed that there is always apprehension of an adverse event: cardiologists prefer to stop increasing the dose of a drug before intolerance to it occurs, especially in ambulatory practice where some adverse events (bradycardia and/or hypotension) are less easily manageable than in the hospital. Second, the concept of the “futility” of increasing the dose of a drug shows that the strategy of increasing the dosage until the maximum tolerated dose and not according to the well-being of the patient is not fully integrated or accepted. In HFpEF, the same trends are observed while no recommendations exist to increase the dose until the maximum tolerated dose in this indication.

Study limitations

The FUTURE survey was an observational cross-sectional survey conducted in HF outpatients followed by cardiologists in private practice with retrospective collection of data at hospital discharge. Therefore, it does not provide an insight into the management of HF by general practitioners. Moreover, although the cardiologists were randomly selected from the French database, we cannot exclude a selection bias with inclusion of a selected HF population. Data were self reported by cardiologists but quality control was performed randomly in 10% of centres, focused on clinical characteristics and HF medical treatment. All data collected and reported by private cardiologists conformed to medical records in the study centres. The precise date of addition of therapy after discharge could not be determined. We enrolled all HF outpatients, whatever their LVEF, age or comorbidities. Therefore, our population was not similar to that usually included in large HF clinical trials. The LVEF cut-off for separating the HFrEF and HFpEF group was arbitrary, based mainly on the CHARM data, and other cut-offs may also have been considered.

Conclusion

In conclusion, the FUTURE survey demonstrated a similar approach to the treatment of HF, regardless of LVEF. This raises the question of how cardiologists integrate the concept of different forms of HF and its management depending on the level of LVEF.

Overall, the rate of prescription of therapies for HF, constantly rising, now appears to be relatively satisfactory and it will probably be difficult to increase such prescriptions due to contraindications or side effects. The latter are more frequent under conditions of everyday practice in older patients with frequent comorbidities, rather than in clinical trials.

Disclosure of interest

I. Leurs and C. Contre were employed by Menarini when the study was conducted. A. Cohen Solal, P. Assyag, F. Beauvais, J.-F. Thebaut and M. Guenoun received consultancy fees for their participation in the study. P. Clerson worked as an independent statistician and received fees.


Acknowledgements

We wish to thank the French National College of Cardiologists for their collaboration and Pierre-Louis Prost for his help. This survey was made possible in part by a grant from Menarini.

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