Pharmacotherapy according to treatment guidelines is associated with lower mortality in a community-based sample of patients with chronic heart failure: a prospective cohort study

Eur J Heart Fail. 2008 Dec;10(12):1236-45. doi: 10.1016/j.ejheart.2008.09.008. Epub 2008 Nov 8.


Background: The effectiveness of chronic heart failure (CHF) pharmacotherapy in unselected cohorts is unknown.

Aims: To estimate the association between quality of CHF pharmacotherapy and all-cause mortality risk.

Methods and results: In a prospective cohort study, 1054 unselected patients with CHF (61% with reduced and 39% with normal left ventricular ejection fraction (LVEF)) were consecutively enrolled. Quality of pharmacotherapy was assessed by calculating a guideline adherence indicator (GAI-3, range 0-100%) based on prescription of beta blockers, angiotensin converting enzyme inhibitors or angiotensin receptor II type-1 blockers, and mineralocorticoid receptor antagonists. Median follow-up in survivors was 595 days (100% complete). In patients with reduced LVEF the median GAI-3 was 67%, and inversely associated with age, CHF severity, and important comorbidities. Mortality rates in GAI-3 categories low/medium/high were 79/30/11 per 100 person-years. In multivariable Cox regression, high GAI-3 was independently predictive of lower mortality risk: hazard ratio (HR) 0.50 (95% confidence interval [CI] 0.32-0.74; P<0.001) vs low GAI-3. This association was also observed in subgroups of high age (HR 0.42, 95%CI 0.27-0.66; P<0.001) and women (HR 0.42, 95%CI 0.23-0.79; P=0.007).

Conclusions: In this community-based cohort with CHF, better implementation of pharmacotherapy was associated with better prognosis in patients with reduced LVEF, irrespective of age and sex.

MeSH terms

  • Adrenergic beta-Antagonists / therapeutic use
  • Aged
  • Angiotensin II Type 1 Receptor Blockers / therapeutic use
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use
  • Cardiovascular Agents / therapeutic use*
  • Chronic Disease
  • Cohort Studies
  • Confidence Intervals
  • Female
  • Guideline Adherence
  • Heart Failure / drug therapy*
  • Heart Failure / mortality
  • Humans
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Odds Ratio
  • Practice Guidelines as Topic
  • Prognosis
  • Prospective Studies
  • Risk Factors
  • Stroke Volume / drug effects
  • Survival Analysis
  • Ventricular Function, Left / drug effects


  • Adrenergic beta-Antagonists
  • Angiotensin II Type 1 Receptor Blockers
  • Angiotensin-Converting Enzyme Inhibitors
  • Cardiovascular Agents