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April 2020 - Henrike Arfsten Henrike Arfsten


Prescription Bias in the Treatment of Chronic Systolic Heart Failure

There is irrevocable evidence that guideline recommended medical therapy with beta-blockers (BB), angiotensin converting enzyme-inhibitors (ACEi), and angiotensin receptor blockers (ARB), uptitrated to target dosage (TD) decreases mortality and hospitalizations in chronic heart failure with reduced ejection fraction (HFrEF) (1). However, physicians seemingly do not sufficiently follow the guidelines and a great number of patients do not receive recommended dosages (2, 3).
A joint study of the Medical University of Vienna and experts of the heart failure working group of the Austrian Cardiology Society examined the dosages prescribed to outpatients based on the national Austrian heart failure registry (3,737 patient data). They found, that after one year aiming for up-titration, significantly less patients were treated with the TD when TD was numerically higher.
As humans are visually deceivable (4, 5), the researcher concluded an influence of the absolute numerical values of recommended TD of equipotent drugs on the prescription behavior of the treating physician. Which means that "milligram-based" subjective weighting of tolerability by the individual physician influences the maximal prescribed dosage. This psychological phenomenon was identified a substantial confounder at least partly responsible for the underuse of BB, ACEi and ARB in HFrEF (6).

Selected Literature

    1. Arfsten H, Goliasch G, Pavo N, Ulmer H, Hulsmann M, Stefenelli T. Prescription Bias in the Treatment of Chronic Systolic Heart Failure. Annals of internal medicine. 2019.
    2. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. European heart journal. 2016;37(27):2129-200.
    3. Greene SJ, Fonarow GC, DeVore AD, Sharma PP, Vaduganathan M, Albert NM, et al. Titration of Medical Therapy for Heart Failure With Reduced Ejection Fraction. Journal of the American College of Cardiology. 2019;73(19):2365-83.
    4. Maggioni AP, Anker SD, Dahlstrom U, Filippatos G, Ponikowski P, Zannad F, et al. Are hospitalized or ambulatory patients with heart failure treated in accordance with European Society of Cardiology guidelines? Evidence from 12,440 patients of the ESC Heart Failure Long-Term Registry. European journal of heart failure. 2013;15(10):1173-84.
    5. Kahneman D, Tversky A. On the psychology of prediction. Psychological Review. 1973;80(4):237-51.
    6. Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision under Risk. Econometrica. 1979;47(2):263-91.
    7. Pavo N, Yarragudi R, Puttinger H, Arfsten H, Strunk G, Bojic A, et al. Parameters associated with therapeutic response using peritoneal dialysis for therapy refractory heart failure and congestive right ventricular dysfunction. PloS one. 2018;13(11):e0206830.
    8. Huelsmann M, Neuhold S, Resl M, Strunk G, Brath H, Francesconi C, et al. PONTIAC (NT-proBNP selected prevention of cardiac events in a population of diabetic patients without a history of cardiac disease): a prospective randomized controlled trial. Journal of the American College of Cardiology. 2013;62(15):1365-72.
    9. Bartko PE, Arfsten H, Heitzinger G, Pavo N, Toma A, Strunk G, et al. A Unifying Concept for the Quantitative Assessment of Secondary Mitral Regurgitation. Journal of the American College of Cardiology. 2019;73(20):2506-17.
    10. Arfsten H, Bartko PE, Pavo N, Heitzinger G, Mascherbauer J, Hengstenberg C, et al. Phenotyping progression of secondary mitral regurgitation in chronic systolic heart failure. European journal of clinical investigation. 2019;49(11):e13159.
    11. Pavo N, Gugerell A, Goliasch G, Bartko PE, Arfsten H, Novak JF, et al. Increased granulocyte membrane neprilysin (CD10) expression is associated with better prognosis in heart failure. European journal of heart failure. 2019;21(4):537-9. Henrike Arfsten Henrike Arfsten
    Medizinische Universität Wien
    Universitätsklinik für Innere Medizin II
    Klinische Abteilung für Kardiologie
    Währinger Gürtel 18-20
    1090 Wien

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