In Pursuit of Optimal Care and Outcomes for Patients with Congestive Heart Failure: Insights from the Past Decade
This chapter provides an integrated summary of current insights on the epidemiology and optimal management of patients with congestive heart failure (CHF) and reviews the authors’ experience of CHF management in the last decade, including results from large clinical trials, demographic and practice pattern analyses, and related health outcomes studies.
CHF is a major public health burden, affecting one percent of the entire Canadian population. Moreover, its incidence and prevalence are increasing, and the mortality risk remains high. In the acute care setting, about one in five patients die during admission. Chronically, the one-year mortality risk for patients with systolic left ventricular dysfunction, who comprise more than three-quarters of all CHF patients, is 25 percent versus 16 percent for patients with predominantly diastolic dysfunction. The principal cause of death in CHF is progression of heart failure, although noncardiac causes, particularly cancer and pulmonary diseases, account for about 30 percent of all deaths. Therapy proven to reduce overall mortality in CHF is presently limited to angiotensin-converting enzyme inhibitors (ACEI) , although angiotensin receptor antagonists, beta blockers, and cardiac allografts appear efficacious in small trials and/or major subsets of CHF patients. Diuretics and digoxin can decrease patient symptomatology and hospitalizations in some patients, but ACEI remain the only medication proven to decrease total hospitalizations. Medications, of themselves, do not improve quality of life in CHF, but medications, in combination with aglobai and seamless approach to care that includes an accent on patient education, are associated with increased patient satisfaction and improved life quality. Optimal care programs are also associated with favorable survival outcomes for CHF patients, which are in the range of that reported from recent CHF clinical trials and contemporary transplant data. However, the optimal effectiveness of therapy for the whole Canadian CHF population at risk is being limited by less than optimal prescription of, and suboptimal compliance with, proven therapy. As well, restrictive reimbursement policies, which limit patient access to physician-prescribed drugs, threaten to add another impediment to population effectiveness of proven CHF therapy. As many as 50 to 75 percent of eligible CHF patients, particularly older patients and women, may not presently be receiving persistent beneficial therapy, which results in unnecessary adverse clinical and fiscal outcomes for themselves and for the nation. Moreover, in contrast to improvements in the acute cardiac diseases, the CHF practice patterns and outcomes appear more difficult to modify. In summary, CHF is an increasingly important and treatable disease in Canada, but its management and outcomes remain less than optimal. As the population ages, CHF will assume even greater relative importance as a chronic and terminal illness. More efficacious medications are needed for this future. In the interim, more effective application of proven therapies, particularly comprehensive and integrated disease management programs, would substantially improve duration and quality of life for patients with CHF.
KeywordsCongestive Heart Failure Diastolic Dysfunction Beta Blocker Acute Care Setting Canadian Cardiovascular Society
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