Is heart failure guideline adherence being underestimated? the impact of therapeutic contraindications

Brett D. Atwater, David Dai, Nancy M. Allen-Lapointe, Sana M. Al-Khatib, Louise O. Zimmer, Gillian D. Sanders, Eric D. Peterson

Research output: Contribution to journalArticlepeer-review

19 Scopus citations


Background: Several studies based on claims data have reported underutilization of evidence-based heart failure (HF) therapies. The degree to which these estimates fail to account for therapeutic contraindications is unclear. Methods: We identified patients with HF and left ventricular ejection fraction ≤45% seen between January 1, 2010, and July 1, 2010, at a tertiary care Veterans Affairs Medical Center. Medical records were abstracted to evaluate utilization of and contraindications to β-blocker, angiotensin-converting enzyme inhibitor, aldosterone antagonist, anticoagulation for atrial fibrillation, implantable cardioverter-defibrillator, and cardiac resynchronization therapies. Results: Of the 178 patients with HF and an ejection fraction ≤45%, 78 (44%) received every guideline-recommended therapy. After accounting for medical contraindications, 77 (72%) of 107 patients received every guideline-recommended therapy. Adherence to recommendations for β-blocker (98%), angiotensin-converting enzyme inhibitor/angiotensin blocker (95%), and anticoagulation (97%) were better than adherence to implantable cardioverter-defibrillator (82%), cardiac resynchronization therapy (59%), or aldosterone antagonist (51%) recommendations. In adjusted analysis, lower New York Heart Association functional class and care by a cardiologist were associated with improved guideline adherence (P <.001). Conclusions: Many patients with HF have therapeutic contraindications, and a failure to account for these may lead to a large underestimation of the true guideline adherence rates.

Original languageEnglish (US)
Pages (from-to)750-e1
JournalAmerican heart journal
Issue number5
StatePublished - Nov 2012
Externally publishedYes

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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