Objective: To evaluate adherence of clinicians to the European guidelines for management of acute heart failure (AHF). Materials and Methods: This was a medical chart–based review study conducted from January to December 2016, including 200 medical records of patients admitted to two major hospitals in the Gaza Strip, Palestine. The AHF management was compared to the European Society of Cardiology (ESC) Guidelines, 2016. Results: The patients' mean age was 66.0 ± 13.0 years. A total of 100 patients (50.0%) were women and 192 (96.0%) had comorbidities including hypertension, diabetes, and heart disease. The most notable finding was that of a very poor standard of documentation, especially for vital signs. Patient management showed mostly moderate to good adherence to guidelines with 189 (94.5%) patients undergoing electrocardiogram, 90 (45.0%) echocardiography, 97 (48.5%) chest X-ray, and 79 patients of 167 (47.3%) receiving vasodilators appropriately. Good adherence was found in checking glucose levels, 176 (88.0%), and application of oxygen (100% with SpO2 < 90%). Some aspects of care showed poor adherence, such as overuse of digoxin in 57 patients (28.5%), of which only 30 (53.4%) had atrial fibrillation and inappropriate use of beta-blockers in two patients who were hypotensive. Furthermore, brain natriuretic peptide was not used at all. Conclusion: The results of this study show suboptimal adherence to the ESC guidelines in management of AHF, reflecting the need to improve awareness of evidence-based medicine among clinicians.
Acute heart failure (AHF) is defined as a rapid onset of new or worsening signs and symptoms of heart failure (HF). It may present as a first occurrence (de novo) or, more frequently, as a consequence of acute decompensation of chronic HF. De novo AHF may be caused by primary cardiac dysfunction, whereas the decompensated HF may be precipitated by several cardiovascular and non-cardiovascular conditions causing rapid development or deterioration of signs and/or symptoms of AHF leading to hospitalization. However, de novo AHF accounts for less than half of admissions. The efficacy of vasopressin antagonism in heart failure outcome study with tolvaptan trial, a randomized controlled trial, reported that 46% of patients were admitted with decompensated HF, whereas 39% were hospitalized for non-cardiovascular comorbid conditions, such as chronic obstructive pulmonary disease, anemia, and hypo/hyperthyroidism.
The most common cause of death in the Gaza Strip is cardiovascular diseases, accounting for 52% of deaths, but no definite statistic about the incidence of AHF and its causes exists. However, in most of the published large registries of AHF including the acute decompensated heart failure national registry (ADHERE), organized program to initiate lifesaving treatment in hospitalized patients with heart failure, and the euroheart failure survey II, the in-hospital mortality ranges from 4% to 7% with a median length of stay between 4 and 11 days. Consequently, AHF requires expert and quick evaluation and management to optimize patient outcome and reduce hospital stay. Clinical guidelines based on the best available evidence are an important tool in this context, offering individual clinicians a guide and memory aid to up-to-date management strategies as well as teams a common ground for efficiently and safely dealing with this clinical emergency.
The Institute of Medicine defines clinical practice guidelines as “statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefit and harms of alternative care options.” They are designed to help physicians in making appropriate decisions with the aim of improving the quality of care.
Currently, no specific guideline for management of AHF in Palestinian Ministry of Health (MoH) hospitals exists. The European Society of Cardiology (ESC) guidelines were used as a reference to assess adherence in previous studies.[10–12] However, a satisfactory level of clinical practice of these guidelines has not been reached yet even in Europe.[13,14] This study describes the patterns of AHF management at two major Gaza Strip hospitals, aiming to identify common strengths and frequent pitfalls as well as examining causes of deviations and necessary improvements to the quality of care.
MaterIals and Methods
This was a medical chart–based review study conducted from January to December 2016 at the cardiology units of two major hospitals located in the Gaza Strip, Palestine. For the purpose of anonymizing the results of this study, each of the two hospitals was given a symbol of either X or Y. This will also support the focus on improving the quality of care and patient safety instead of only targeting specific hospitals.
No institutional review boards exist in the Gaza Strip. Ethical approval for this study was obtained from the Human Resources Department of the Palestinian MoH, which is the body in Gaza to issue ethical and administrative approvals for studies involving humans. All data were kept completely confidential.
Study population and sample
The Palestinian MoH has been continuously working to improve the documentation system over the preceding years. Therefore, the use of patient records of the final year (2016) as a data source was deemed to be appropriate. A total of 410 patients with AHF were admitted to the selected hospitals during the year of 2016. Inclusion criteria for participation were good medical documentation with appropriate International Classification of Diseases, 10th revision (ICD10) code of I50, admission between January 2016 and December 2016, and patients who had clinical symptoms and signs of AHF. On the basis of these criteria, 200 medical records (of 410) were included in this study.
The ratio between the numbers of selected records from each hospital was determined by the same ratio for geographical coverage of the Gaza Strip population with hospital X covering twofold compared to that with hospital Y.
This study was intended as a baseline for future quality improvement projects. The required sample size was calculated using stata software version 14.0 (StataCorp, College Station, Texas, USA) with a power of 80.0% and was found to be 183, assuming that the current adherence to every AHF diagnostic measure and medical therapy is 50.0% with the aim to improve this to 65.0% in future studies. However, we preferred to enroll 200 cases to compensate for possible missing data. Data were collected by the authors from the medical files with the help of a data collection sheet covering all required items, including demographic characteristics (age and sex), medical history and clinical presentation (comorbidities and precipitating factors), vital signs (blood pressure, temperature, heart rate, and respiratory rate), and transcutaneous arterial O2 saturation (SpO2), diagnostic measures, and medical treatments. The management details were then compared to the selected standard, the ESC guidelines (2016), with regard to diagnosis and treatment of AHF. These guidelines were chosen as a reference in this study; first, because they are more feasible than other guidelines, especially with the paucity of resources in the Gaza Strip. Second, previous studies showed that adherence to ESC guidelines for management of HF was associated with improved outcomes.[10–12] On the basis of ESC guideline (2016) recommendations, appropriate use and interpretation of plasma brain natriuretic peptide (BNP) level, cardiac troponins, 12-lead electrocardiogram, chest X-ray, echocardiography, complete blood count, liver function tests, serum blood urea nitrogen (BUN) level, creatinine level, electrolytes (sodium and potassium), glucose level, and thyroid-stimulating hormone (TSH) were evaluated. Furthermore, general principles of inpatient care were reviewed, including oxygen therapy, diuretics, vasodilators, inotropic agents, vasopressors, venous thromboembolism (VTE) prophylaxis, digoxin, beta-blockers (BB), and opiates.
Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) software, version 22 (IBM, Chicago, Illinois, USA). Data analysis was based on descriptive statistics including frequencies and percentages as well as comparisons with the recommended guidelines used as standard. Chi-square test was used to test for associations between sociodemographic data of the patients and adherence to diagnostic measures and therapies for AHF with a P value of ≤ 0.05 considered to be significant. Abnormal vital signs were defined as follows: high temperature (fever) if body temperature > 38.3°C (101°F), tachypnea if respiratory rate was > 20 breath/min, and bradycardia if heart rate was < 60 beat/min or tachycardia if it was > 100 beat/min. The count of missing vital signs has been reported separately in their tables.
Abnormal laboratory values were defined as follows: hyperglycemia if random blood sugar level was > 11.1 mmol/L, anemia if serum hemoglobin level was < 12.0 g/dL in females and < 13.0 g/dL in males, high serum BUN level if it was > 23 mg/dL for both males and females, high serum creatinine level if it was > 1.3 mg/dL in males and if > 1.1 mg/dL in females, and hyperkalemia if serum potassium levels were > 5.5 mmol/L.
Two hundred medical records for patients with AHF were reviewed and categorized into three age groups. The mean age of the total sample was 66.0 ± 13.0 years. The age distribution was as follows: 64 patients (32.0%) were ≤ 60 years of age, 58 patients (29.0%) were aged 61–69 years, and 78 patients (39.0%) were ≥ 70 years of age. Interestingly, 100 patients (50.0%) were females. Of the total, 192 patients (96.0%) had comorbidities including hypertension, diabetes, and heart disease [Table 1]. Some important triggering factors for AHF were noticed including hyperglycemia (n = 155, 77.3%), anemia (n = 101, 50.5%), high blood pressure (n = 80, 40.0%), infection (n = 66, 33.0%), and hyperkalemia (n = 43, 21.4%). Systolic blood pressure (SBP) was documented for 174 patients (87.0%). Other documented vital signs are described in Table 2. BNP was not used at all and troponins were obtained only in 11 patients (5.5%). In contrast, better adherence to some other key tests (e.g., electrocardiogram and chest X-ray) was noticed but still lower than the standards. However, there was good attainment of nonspecific investigations (e.g., complete blood count) that were requested mainly to identify any triggering factor for decompensated HF, with one deviation from this being TSH [Table 3]. Creatinine and urea levels were obtained in 187 and 178 patients (93.5% and 89.0%, respectively) with elevated values observed in 41 and 186 of them (45.5% and 96.6%, respectively). A significant association was observed between obtaining troponins and creatinine levels with the age group of the patient with troponins being most frequently requested in the younger age group (≤ 60 years) and creatinine in the oldest (≥ 70 years). In addition, having comorbidities was significantly associated with requesting electrolytes, glucose level, and complete blood count. It was found that only 25 patients (12.5%) needed oxygen therapy at the emergency room or on admission, based on the medical record documentation [Table 4]. Vasodilators were given to 93 patients (55.7%) where SBP was > 90 mm Hg in 79 of them (84.9%). BB were used in 114 patients (57%) (80 [71.2%] bisoprolol and 34 [29.8%] carvedilol). It was noted that BB were given to two patients who were hypotensive. Digoxin (0.25 mg) was given to 57 cases (28.5%) of which 31 (54.3%) had atrial fibrillation.
No significant association was observed between patients' sociodemographic data and adherence to different AHF therapies with the exception of the association between sex and receiving oxygen therapy.
This study showed overall good adherence to the ESC guidelines in management of patients with AHF. However, deficiencies were found in requesting cardiac investigations (e.g., BNP) and documentation of vital signs. In addition, there was an underuse of oxygen, overuse of digoxin, as well as inappropriate use of BB. Moreover, an alarming standard of poor documentation was evident in the notes of patients seen with AHF, posing an unacceptable level of risk to patient safety.
Large registries have shown that 50% of patients with AHF have elevated SBP at presentation to the emergency room.[21,22] Consequently, patients with AHF should be immediately evaluated and monitored for vital signs, especially SBP, even before hospitalization. SBP also has a central role as a predictor of morbidity and mortality, and accordingly, it was suggested that initial treatment would be more effective if it was based on presenting SBP. Respiratory rate, temperature, and pulse rate are also important to detect a cause for the decompensation (e.g., infection or hyperthyroidism), as well as measuring the SpO2, which will determine whether the patient should receive oxygen therapy, when SpO2 is below 90%. However, these items were not well-documented in this study. In addition, the discordance between the high number of patients who received BB and digoxin with the low reported number of AF cases could be related to poor documentation of AF. Similar observations of poor documentation were made across other specialties in Gazan hospitals, showing persistent poor awareness of clinicians of the important role of good documentation for ensuring patient safety and quality care.
Adherence to diagnostic measures
The diagnosis of AHF is a particular challenge because it can only be confirmed in 40%–50% of suspected cases as symptoms and signs are often nonspecific and may overlap with other diagnoses. The measurement of plasma BNP levels has been recommended in the ESC guidelines because of its high negative predictive value to rule out AHF as the cause of acute dyspnea. However, in this study, it was surprising to find that this test was not used at all as clinicians were uncertain about its incremental benefit and cost-effectiveness. This was also observed in previous studies[29–31] and showed the paucity of evidence-based practice in Gazan hospitals, as well as deficiencies in knowledge and awareness of current practice. Similar deficiencies were also found in other studies in Gaza and appeared to be one of the main barriers to adherence to guidelines and implementation of evidence-based practice not only in cardiovascular medicine but also in other medical fields.
Despite the ESC recommendations to measure troponin levels in AHF, this was only carried out in few patients. A possible cause for this could be their challenging interpretation as they could also be elevated in myocardial ischemia. Chest X-ray was performed in about half of the cases where physicians could consider it may be normal in one of five patients admitted with AHF. The use of echocardiography was mainly targeted at hemodynamically unstable patients or within 48 h when cardiac structure and function were either not known or may have changed since previous studies. However, only 90 patients (45.0%) had an echocardiogram in this study. Paucity of resources and a high workload in Gaza hospitals could be a main contributor to this. Some patients may, therefore, undergo echocardiography after discharge in the private sector and many not at all.
Adherence to acute heart failure therapies
Intravenous loop diuretics are the most commonly used decongestive AHF treatments, and according to the ESC guidelines, they should be administered to all patients with AHF, which was carried out for most but not all in this study.
The ESC guidelines also recommended using vasodilators in those who have an SBP > 90 mm Hg to improve symptoms and reduce congestion because their use was associated with lower mortality and shorter length of hospital stay, and a delay in administration was associated with a higher mortality. In this study, the adherence to this was not good; on the contrary, few patients with an SBP < 90 mm Hg received vasodilators. A possible reason for this low percentage of vasodilator use, despite their beneficial effect on mortality or morbidity, could be the fear by clinicians of concurrent presence of an acute neurological event and ensuing hypotension. However, actual presence of mental status changes was not recorded in the notes, making this practice another example of poor awareness of recent evidence as well as poor documentation in medical files. Another explanation for the discordance with the guidelines in the use of diuretics and vasodilators could be the possibility of deteriorating renal function by intravascular volume reduction and activation of neurohormonal pathways with negative impact on cardiac and renal function, as shown in a study by Butler et al. Such experiences combined with the lack of local guidelines and poor awareness of international guidelines could explain the poor adherence of clinicians to the use of diuretics and vasodilators as recommended by the ESC guidelines. The lack of protection for clinicians in Gaza, which is offered by agreed management guidelines, produces fear of medicolegal consequences and might contribute to their nonadherence to international guidelines.
The suboptimal adherence to VTE prophylaxis has been addressed by some clinicians who claimed that patients immobilized for an acute medical disease may experience VTE despite thromboprophylaxis but have a similar outcome to those for whom thromboprophylaxis was not prescribed. A similar observation was made in another study by Merah et al. In fact, other studies that were conducted in the Gaza Strip on VTE prophylaxis and therapy showed poor adherence to the recommended standards, showing a need of increasing awareness of clinicians on this issue and implementation of guidelines across different departments (unpublished observations with a permission for citation taken from first authors: Abuowda Aoda et al. and Elshami et al.).
The high use of BB and digoxin in the absence of AF could be explained by the awareness of clinicians about the fact that acute cessation of BB is physiologically close to inotropic support, so instead of giving inotropic agents, clinicians tend to give BB for a short period then stop it to get that response, as reported by Jondeau and Milleron. Another possibility could be that from the 68% of patients who had coexisting hypertension, many were already taking long-term BB, so they could not be added to their treatment or withheld, as sudden stopping of BB might trigger angina, increasing the risk of sudden death.[40,41] However, systematic documentation of current medications was poor and therefore, the exact number remained unknown. A meta-analysis by Prins et al. confirmed improved mortality if BB are maintained during admission to hospital, but other studies came to different conclusions.[43–46] Similarly, controversy remains on the use of digoxin with some studies showing an increase in mortality to be associated with the use of digoxin in certain patients.[47–52] However, despite this mortality risk, a significant proportion of patients in this study were still prescribed digoxin. This is consistent with a randomized HF study in which approximately 30% of patients with New York Heart Association class II/III were receiving digoxin.
However, different economic circumstances and varying availability of facilities between Gaza and the European countries could cause different management to ensure cost-effectiveness as well as quality of care. Komajda et al. showed that the economic factor may play an important role in the variation of adherence rates in different countries or even in various regions across Europe, where they found that adherence to the guidelines was lower in Central/Eastern European countries.
The ESC guidelines also recommend using opiates to relieve dyspnea and anxiety in patients with AHF with caution as nausea and hypopnea may occur. Morphine was given to approximately a third of the study patients because clinicians were concerned about its association with higher rates of mechanical ventilation, intensive care unit admission, and death as it may depress the central nervous system and control of respiration. This is in concordance with a large study, including 147,000 patients by Peacock et al. (ADHERE registry), where almost 21,000 patients received morphine and after adjusting for factors known to be associated with increased hospital mortality, morphine remained an independent predictor of mortality. Some physicians in Gaza justified their nonuse of morphine with the 2013 American Heart Association guidelines, which did not mention this as a therapeutic option in patients with AHF.
The low use of morphine in Gaza hospitals might also be a reflection of the physicians' lack of security in case of complications, driving them to avoid its use, even if patients with AHF might benefit. Therefore, a proper medicolegal policy should be developed and adopted to protect both physicians' and patients' rights. This will help to reduce physicians' fear and concerns toward using therapies with high complication rates to improve safe patient management.
Barriers and challenges to better adherence
The barriers for better adherence to clinical guidelines in the context of Gaza can be either environment related or guideline related.
There are three main environment-related barriers. First, the lack of resources and fluctuating availability of diagnostic tests (such as with BNP), which often depends on what is received as donations. Second, the lack of an electronic documentation system, which could facilitate and improve accuracy of medical documentation. So far, the cost has been prohibiting, although plans are underway to introduce such a system. Third, the heavy workload of physicians in governmental hospitals possibly contributes to observed weaknesses. Irving et al. showed an inverse relationship between the consultation length and physicians' stress, raising the possibility of work overload contributing to nonadherence to guidelines, as physicians lack adequate time for their implementation. However, the major guideline-related barrier is the lack of local guidelines designed by the MoH and tailored to local resources. Agreed and adopted local guidelines together with a medicolegal policy could provide physicians with security and address their concerns as well as support delivery of high-quality care to patients.
Strengths and limitations
The main strength of this study was the inclusion of the two major hospitals in the Gaza Strip, giving a good view on management of AHF in Gazan hospitals with future opportunities to improve the quality and safety of health care.
The limitations included the poor documentation system in these hospitals, raising the possibility that some investigations and therapies were not documented appropriately, possibly exaggerating deviation from the guidelines. Another limitation was the lack of information on clinical outcomes, making it impossible to study the association of guideline adherence to the outcome.
Future implications and recommendations
This study identified an urgent need for the development of local guidelines as well as promotion of evidence-based practice among clinicians. In addition, the current documentation system has to be improved urgently to facilitate the process of evaluating and improving clinical practice. Furthermore, a medicolegal policy should be created to protect both physicians and patients.
Suboptimal adherence to ESC guidelines in AHF management was found in Gaza Strip hospitals. This could be attributed to the lack of local guidelines as well as deficient awareness of international guidelines by clinicians. Furthermore, the poor medical record and registry systems cause loss of data, exaggerating deviation from the recommended guidelines. Future studies are needed to assess the impact of the implementations of recommendations on the rate of adherence to AHF management guidelines.
Financial support and sponsorship
The authors disclosed no funding related to this article.
Conflicts of interest
The authors disclosed no conflicts of interest related to this article.
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