Real-world management of heart failure in the Netherlands
Real-world management of heart failure in the Netherlands
S. Koudstaal 0 1 2
F. W. Asselbergs 0 1 2
0 Farr Institute of Health Informatics Research , London , UK
1 Department of Cardiology, University Medical Centre Utrecht , Utrecht , The Netherlands
2 S. Koudstaal
In the era of evidence-based medicine, clinicians
experience on a daily basis that its holy grail, the randomised
clinical trial, excels at internal validity but frequently lacks
external validity. In fact, only 13% of patients seen with
heart failure in daily clinical practice would have matched
the stringent inclusion and exclusion criteria in heart
failure clinical trials [
]. As a result, everyday discrepancies
are still largely resolved by the clinical judgement of the
treating physician. On the other hand, we need trials to test
safety and efficacy of new drugs. In the field of heart failure,
we have seen the introduction of first-in-class drugs that
harness the potential to bring about substantial
improvements in heart failure care and survival [
guidelines for heart failure treatment are frequently and
thoroughly updated, in particular for heart failure with reduced
ejection fraction (HFrEF) [
]. Collectively, there is a need
to connect these two worlds to promote the uptake and
implementation of evidence-based medicine in the real world.
There is a growing recognition that real-world registries
can increase our awareness of the huge gap between daily
clinical practice and clinical trials [
]. So far, there have
been heart failure registries that assessed medication use,
but their demographics still showed there is considerable
residual selection bias as these registries still lack patients
who frequently are underrepresented in clinical trials, such
as women, the elderly, and patients with multiple
In this issue of the Netherlands Heart Journal, Brugts
et al. present the framework and forthcoming of a new
realworld registry in the Netherlands that included over 10,000
patients with heart failure, called CHECK-HF [
Unselected patients diagnosed with chronic heart failure at Dutch
outpatient clinics were included, of those the vast majority
being diagnosed with HFrEF (79%). With a mean age of
73 years and 40% of patients being female, CHECK-HF
proves to be a better resemblance of heart failure seen in
the real world than previous heart failure registries.
Medication uptake was carefully recorded, including dosages
of drugs. Particularly the latter will be helpful in
understanding how well we are treating heart failure. The central
question is, can we improve guideline adherence by simply
It comes as no surprise that quality of care can be
considerably improved by simply making best use of the
therapeutics we already have. For example, it is known for more
than a decade that black Americans are among those with
the highest hypertension-related mortality and that
interventions with calcium channel blockers and angiotensin
converting enzyme inhibition in these patients are most
]. Yet, only very recently, the New England Journal
of Medicine published a cluster-randomised intervention
that aimed to measure and intervene on high blood
pressure levels at the patients’ local barbershop. This simple
intervention led to a substantial decline in uncontrolled
]. Novel intervention, old drugs. Why should
it be any different in the field of heart failure? The authors
believe that heart failure prescription rates in the real world
are modest at best and that renin angiotensin system
antagonists and/or betablockers dosages are only sporadically on
target levels. If that is confirmed in a contemporary cohort
such as CHECK-HF, then the real contribution to
improving heart failure care is increasing the guideline adherence
and use what’s already out there. No doubt that if all HFrEF
patients are treated with adequate dosages of neprilysin
inhibitors/angiotensin II receptor blockers, betablockers,
mineralocorticoid receptor antagonists, receive iron
supplementation when iron deficient, are actively counselled with
regard to lifestyle habits, and, last but not least, receive
appropriate device therapy, future heart failure trials will
probably look increasingly similar to clinical trials in the field of
acute coronary syndromes and antithrombotic agents—that
is, we will need to enrol more than 15,000 patients to detect
minute differences in mortality on a statistical level.
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
Neth Heart J
1. Lenzen MJ , Boersma E , Scholte WJM , et al. Under-utilization of evidence-based drug treatment in patients with heart failure is only partially explained by dissimilarity to patients enrolled in landmark trials: a report from the Euro Heart Survey on Heart Failure . Eur Heart J . 2005 ; 26 : 2706 - 13 . https://doi.org/10.1093/eurheartj/ ehi499.
2. PARADIGM-HF Investigators and Committees. Angiotensin-Neprilysin inhibition versus enalapril in heart failure . N Engl J Med . 2014 ; https://doi.org/10.1056/NEJMoa1409077.
3. Ponikowski P , Voors AA , Germany SDA , 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 . Eur Heart J . 2016 ; https:// doi.org/10.1093/eurheartj/ehw128.
4. Yancy CW , Jessup M , Bozkurt B , Butler J. 2017 ACC/ AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure . Circulation . 2017 ; https://doi.org/10.1161/ CIR.0000000000000509.
5. Koudstaal S , Pujades-Rodriguez M , Denaxas S , et al. Prognostic burden of heart failure recorded in primary care, acute hospital admissions, or both: a population-based linked electronic health record cohort study in 2.1 million people . Eur J Heart Fail . 2017 ; 19 https://doi.org/10.1002/ejhf.709.
6. Maggioni AP , Orso F , Calabria S , et al. The real-world evidence of heart failure: findings from 41 413 patients of the ARNO database . Eur J Heart Fail . 2016 ; 18 : 402 - 10 . https://doi.org/10.1002/ejhf.471.
7. Gerber Y , Weston SA , Redfield MM , et al. A contemporary appraisal of the heart failure epidemic in olmsted county , Minnesota , 2000 to 2010 . JAMA Intern Med . 2015 ; 175 : 996 - 1004 . https://doi. org/10.1001/jamainternmed. 2015 . 0924 .
8. https://www.nvvc.nl/nieuws/nvvc-nieuws/item/1389/Start+ onderzoek+ naar+betere+pati%C3%ABntenregistratie+hartfalen+ en+boezemfibrilleren . Accessed 20 Mar 2018 .
9. http://www.nvvcconnect. nl/hartfalen. Accessed 20 Mar 2018 .
10. Maggioni AP , Dahlström U , Filippatos G , et al. EURObservational research programme: regional differences and 1-year follow-up results of the Heart Failure Pilot Survey (ESC-HF Pilot) . Eur J Heart Fail . 2013 ; 15 : 808 - 17 . https://doi.org/10.1093/eurjhf/hft050.
11. Brugts JJ , Linssen GCM , Hoes AW , Brunner-La Rocca HP , et al. Real-world heart failure management in 10,910 patients with chronic heart failure in the Netherlands: design and rationale of the chronic heart failure ESC guideline-based Cardiology practice Quality project (CHECK-HF) . Neth Heart J . 2018 ; https://doi.org/ 10.1007/s12471-018-1103-7.
12. Ferdinand K , Armani A . The management of hypertension in African Americans . Crit Pathw Cardiol . 2007 ; 6 : 67 - 71 .
13. Victor RG , Lynch K , Li N , et al. A cluster-randomized trial of blood-pressure reduction in black barbershops . N Engl J Med . 2018 ; https://doi.org/10.1056/NEJMoa1717250.