Risk-treatment mismatch in heart failure
Patients with heart failure at high risk of death are least likely to receive treatment with angiotensin-converting enzymes, angiotensin II receptor blockers and beta-blockers, say Canadian researchers.
They analysed data from 1,418 hospital patients in Ontario, Canada, aged
79 years or younger, with a left ventricular ejection fraction of 40 per
cent or less.They found that as predicted risk of death increased, discharge
prescriptions for these drugs decreased. This pattern was maintained for
up to one year after discharge.
The researchers suggest several possible explanations for their findings,
including an under appreciation of the benefits of therapy and the need
for multiple medicines. They also suggested doctors may be distracted
from heart failure care for patients with multiple co-morbid conditions.
They note, however, that the treatment/risk mismatch persisted despite
exclusion of patients with lifelimiting co-morbidities.
Other reasons could be an uncertainty about risk versus benefit in patients
who are under-represented in clinical trials and perceived potential for
harm associated with treatment in high-risk patients, the researchers
say.
“Further study is needed to quantify the adverse consequences attributable
to the mismatch between risk and treatment rates and may also identify
potential solutions to correct this undesirable phenomenon,” the
researchers conclude. (JAMA 2005;294:
1240). |
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