SUrvey of Guideline Adherence for Treatment of Systolic Heart Failure in Real World (SUGAR): a multi-center, retrospective, observational study

BACKGROUND: Clinical practice guidelines have been slowly and inconsistently applied in clinical practice, and certain evidence-based, guideline-driven therapies for heart failure (HF) have been significantly underused. The purpose of this study was to survey guideline compliance and its effect on clinical outcomes in the treatment of systolic HF in Korea. METHOD AND RESULTS: The SUrvey of Guideline Adherence for Treatment of Systolic Heart Failure in Real World (SUGAR) trial was a multi-center, retrospective, observational study on subjects with systolic HF (ejection fraction <45%) admitted to 23 university hospitals. The guideline adherence indicator (GAI) was defined as a performance measure on the basis of 3 pharmacological classes: angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor II blocker (ARB), beta-blocker (BB), and aldosterone antagonist (AA). Based on the overall adherence percentage, subjects were divided into 2 groups: those with good guideline adherence (GAI >/=50%) and poor guideline adherence (GAI <50%). We included 1319 regional participants as representatives of the standard population from the Korean national census in 2008. Adherence to drugs at discharge was as follows: ACEI or ARB, 89.7%; BB, 69.2%; and AA, 65.9%. Overall, 82.7% of the patients had good guideline adherence. Overall mortality and re-hospitalization rates at 1 year were 6.2% and 37.4%, respectively. Survival analysis by log-rank test showed a significant difference in event-free survival rate of mortality (94.7% vs. 89.8%, p = 0.003) and re-hospitalization (62.3% vs. 56.4%, p = 0.041) between the good and poor guideline-adherence groups. CONCLUSIONS: Among patients with systolic HF in Korea, adherence to pharmacologic treatment guidelines as determined by performance measures, including prescription of ACEI/ARB and BB at discharge, was associated with improved clinical outcomes

Unadjusted event-free curves for overall mortality and re-hospitalization in HF patients with good and poor guideline adherence at discharge.

<p>(A) overall mortality and (B) re-hospitalization. HF, heart failure; Good, good guideline adherence; Poor, poor guideline adherence; Line, good guideline adherence; dotted line, poor guideline adherence.</p

Baseline characteristics of the study population.

<p>AA, aldosterone receptor antagonist; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; BB, beta-blocker; BMI, body mass index; BNP, b-type natriuretic peptide; BUN, blood urea nitrogen; CABG, coronary bypass graft surgery; CK-MB, creatine kinase-MB fraction; DBP, diastolic blood pressure; ECG, electrocardiography; HR, heart rate; IQR, interquartile range; LA AP, left atrium anterior-posterior; LBBB, left bundle branch block; LVEDD, left ventricular end diastolic dimension; LVEF, left ventricular ejection fraction; NT-proBNP, N-terminal-proBNP; NYHA, New York Heart Association; PAOD, peripheral artery obstructive disease; PCI, percutaneous coronary intervention; PTCA, percutaneous transluminal coronary angioplasty; SBP, systolic blood pressure; SD, standard deviation</p

Drug adherence.

<p>ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor II blocker</p

Dataset for the study population.

<p>LVEF, left ventricular ejection fraction; f/u, follow-up.</p

Adjusted Cox-regression analysis for 1-year mortality at in subgroups according to guideline adherence: Forest plot.

<p>HTN, hypertension; DM, diabetes mellitus; HF, heart failure; LVEF, left ventricular ejection fraction; Cr, creatinine.</p

Relationship between performance measures/guideline adherence at discharge and clinical outcomes.

<p>ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; BB, beta-blocker; AA, aldosterone antagonist; CI, confidence interval; HR, hazard ratio; NYHA, New York Heart Association</p>*<p>Adjusted for age; history of heart failure, ischemic heart failure, diabetes mellitus, and peripheral vascular disease; diastolic blood pressure; blood urea nitrogen; serum creatinine, sodium, and potassium; hemoglobin levels; and NYHA functional classification.</p