Importance of in-hospital initiation of evidence-based medical therapies for heart failure—a review

Abstract

Patients who have had heart failure (HF) face very high risks of hospitalization and mortality. Despite the compelling scientific evidence that angiotensin-converting enzyme inhibitors, aldosterone antagonists, and beta blockers decrease rates of hospitalization and mortality in patients who have had HF, these life-prolonging therapies continue to be underused. Many studies in a variety of clinical settings have documented that important numbers of patients who have had HF are not receiving treatment with these evidence-based therapies, which are recommended by national guidelines, when guided by conventional care. This HF treatment gap results from a variety of complex issues, including lack of systems and disease management programs. This gap in beta-blocker therapy may be due in part to persisting perceptions, despite recent evidence to the contrary, that it should be delayed until patients who developed HF have been stable for 2 to 4 weeks after hospital discharge and that its initiation results in a substantial risk of worsening HF. Conversely, recent clinical trial evidence has substantiated that beta blockers can be safely initiated for patients with HF in the hospital and that there are early benefits, including decreased risks of mortality and hospitalization for worsening HF. It has become increasingly evident that in-hospital initiation of evidence-based cardiovascular therapies and patient education have a positive effect on long-term patient compliance and clinical outcomes. Adopting in-hospital initiation of these therapies as the standard of care (in the absence of contraindications or intolerance) in patients who have HF and stabilized systolic dysfunction could substantially improve treatment rates, decrease the risk of future hospitalizations, and prolong life in the large number of patients who are hospitalized each year for HF.