European Heart Journal (2003) 24, 464474

The EuroHeart Failure Survey programme

a survey on the quality of care among patients
with heart failure in Europe
Part 2: treatment

Paris, France; b Zu
rich, Switzerland; c Go
teborg, Sweden; d Kingston upon Hull, UK; e Valencia, Spain;
g
h
Clichy, France; Berlin, Germany; Bergamo, Italy; i Groningen, The Netherlands; j Birmingham, UK;
k
Warsaw, Poland; l Lisbon, Portugal; m Moscow, Russia; n Budapest, Hungary; o Prague, Czech Republic;
p
Department of Primary Care & General Practice, University of Birmingham, UK; q Practice, Newcastle, UK
f

Received 6 September 2002; accepted 18 September 2002

KEYWORDS
Heart failure;
Medical treatment;
Survey

Background National surveys suggest that treatment of heart failure in daily practice
differs from guidelines and is characterized by underuse of recommended medications. Accordingly, the Euro Heart Failure Survey was conducted to ascertain how
patients hospitalized for heart failure are managed in Europe and if national variations
occur in the treatment of this condition.
Methods The survey screened discharge summaries of 11 304 patients over a 6-week
period in 115 hospitals from 24 countries belonging to the ESC to study their medical
treatment.
Results Diuretics (mainly loop diuretics) were prescribed in 86.9% followed by ACE
inhibitors (61.8%), beta-blockers (36.9%), cardiac glycosides (35.7%), nitrates (32.1%),
calcium channel blockers (21.2%) and spironolactone (20.5%). 44.6% of the population
used four or more different drugs. Only 17.2% were under the combination of diuretic,
ACE inhibitors and beta-blockers. Important local variations were found in the rate of
prescription of ACE inhibitors and particularly beta-blockers. Daily dosage of ACE
inhibitors and particularly of beta-blockers was on average below the recommended
target dose. Modelling-analysis of the prescription of treatments indicated that the
aetiology of heart failure, age, co-morbid factors and type of hospital ward influenced
the rate of prescription. Age <70 years, male gender and ischaemic aetiology were
associated with an increased odds ratio for receiving an ACE inhibitor. Prescription of
ACE inhibitors was also greater in diabetic patients and in patients with low ejection
fraction (<40%) and lower in patients with renal dysfunction. The odds ratio for receiving a beta-blocker was reduced in patients >70 years, in patients with respiratory

* Corresponding author. Michel Komajda, Institut de Cardiologie, GH Pitie

-Salpe
trie
`re, 47-83 Bld de l'Ho
pital, 75013 Paris,
France.
0195-668X/03/$ - see front matter 2003 Published by Elsevier Science Ltd on behalf of The European Society of Cardiology.
doi:10.1016/S0195-668X(02)00700-5

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The Study Group of Diagnosis of the Working Group on Heart Failure of

the European Society of Cardiology *, M. Komajda a, F. Follath b,
K. Swedberg c, J. Cleland d, J.C. Aguilar e, A. Cohen-Solal f, R. Dietz g,
A. Gavazzi h, W.H. Van Gilst i, R. Hobbs j, J. Korewicki k, H.C. Madeira l,
V.S. Moiseyev m, I. Preda n, J. Widimsky o, N. Freemantle p,
J. Eastaugh p, J. Mason q

Euro Heart Survey

465
disease and increased in cardiology wards, in ischaemic heart failure and in male
subjects. Prescription of cardiac glycosides was significantly increased in patients
with supraventricular tachycardia/atrial fibrillation. Finally, the rate of prescription
of antithrombotic agents was increased in the presence of supraventricular arrhythmia, ischaemic heart disease, male subjects but was decreased in patients over 70.
Conclusion Our results suggest that the prescription of recommended medications
including ACE inhibitors and beta-blockers remains limited and that the daily dosage
remains low, particularly for beta-blockers. The survey also identifies several important factors including age, gender, type of hospital ward, co morbid factors which
influence the prescription of heart failure medication at discharge.
2003 Published by Elsevier Science Ltd on behalf of The European Society of
Cardiology.

Introduction

Patients and methods

A detailed description of the patient population and
of the methodology used in this survey are provided
in the diagnosis paper. In brief, 11 304 patients
from 24 countries belonging to the ESC, including
countries from Western, Eastern and Northern
Europe and the Mediterranean, were enrolled with
suspected or confirmed heart failure in 60 hospital
clusters that included 116 hospitals. The average
age was 71.3 years and 53% were males. Heart
failure was recorded for the first time and the index
admission in 27% of patients, whilst 56% of patients
had a diagnosis of heart failure prior to the index
admission. Seventy percent of patients had experienced at least one previous hospital admission in
the 2 years preceding enrolment.

(%)
ACE inhibitors
Angiotensin II receptor antagonists
Antithrombotic therapy (any)
Aspirin
Beta-Blockers
Calcium channel blockers
Cardiac glycosides
Diuretics
IV inotropic agents
Nitrates
Spironolactone

61.8 (4085.1)
4.5 (1.914)
77.6 (57.792.7)
29.1 (27.173)
36.9 (1065.8)
21.2 (9.833.4)
35.7 (17.353.5)
86.9 (64.296.4)
7.2 (0.519.5)
32.1 (6.370.6)
20.5 (5.758.5)

Methods
Modelling results for prediction of
treatment on Euro heart data
In order to assess the relationship between variables and an outcome or event and to consider
associations in a multivariate context, we performed non-linear mixed models. Specifically, we
used a logit link function and binomial error to
identify any characteristics of patients which were
predictive of different drug treatments. We exploited a hierarchical approach to data modelling in
which clusters were defined as random effects.8
Conditioning for country made no material difference to the results. All analyses were conducted
using SAS 8.1.

Results
Table 1 gives the proportion of patients prescribed
various major heart failure medications during
hospitalization overall: diuretics were the most
commonly prescribed treatment for heart failure
(86.9%) followed by ACE inhibitors (61.8%), betablockers (36.9%), cardiac glycosides (35.7%),
nitrates (32.1%), calcium channel blockers (21.2%)

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Chronic heart failure (CHF) is a major health problem and is associated with a high morbidity and
mortality.13 Various national surveys have shown
that medical management of CHF is characterized
by polypharmacy and by the underuse of recommended medications.46 Since 1997, the Guidelines
of the European Society of Cardiology (ESC) have
recommended routine use of ACE inhibitors and
beta-blockers for the management of heart failure
due to left ventricular systolic dysfunction, a recommendation that has recently been reinforced by
further data from randomized trials and revised
guidelines.7 There is also a rapid change in the
perception of heart failure management, based
on recent trial evidence. The Euro Heart Failure
programme is the first pan-European survey to
describe the clinical profile and treatment of
patients hospitalized for or with heart failure, a key
event that provides an opportunity for improved
diagnosis and treatment. The survey provides
detailed information on how current recommendations are implemented in patients who have been
hospitalized.

Table 1 Rate of prescription of the major heart failure

medication in the overall population (n11 016)

466
Table 2

Euro Heart Survey

Drug therapy according to ejection fraction. Rate of prescription in percentage (when available)

ACE inhibitors
Angiotensin II antagonists
Beta-blockers
Calcium channel blockers
Digitalis
Diuretic agents (any)
Inotropic agents
Loop diuretics
Nitrates

EF 40%
(%) (n=3969)

EF <40%
(%) (n=2248)

Difference

95% CI

63.2
4.9
44.5
25.9
31.3
83.2
7.1
75.4
47.1

79.9
6
48.9
12.4
42.7
87.9
11.1
82
48.3

16.7
1.1
4.4
13.53
11.4
4.7
4.0
6.5
1.2

14.3 to 19.1
0 to 2.3
1.7 to 7.1
15.6 to 11.5
8.7 to 14.0
2.8 to 6.6
2.4 to 5.6
4.3 to 8.7
1.5 to 4.0

Note that patients who did not have left ventricular ejection fraction (LVEF) reported are not shown on this table. Patients who
did not have LVEF measured were much less likely to receive an ACE inhibitor or beta-blocker.

Diuretics
Furosemide
Spironolactone
Thiazides
Amiloride
Torasemide
Bumetanide
Metolazone
Triamterene

87.7
23.6
11.5
6.4
3.9
3
1.3
1.1

ACE inhibitors

Beta-blockers

Enalapril
Captopril
Ramipril
Perindopril
Lisinopril
Other

Metoprolol
Atenolol
Bisoprolol
Carvedilol
Sotalol
Other

34.9
21.8
20.1
10.3
9.7
7.8

40.3
24.4
14.6
13.1
5.1
9

and spironolactone (20.5%). Angiotensin receptor

antagonists were not prescribed frequently for
patients with heart failure. Only 17.2% of the
population received the combination of a diuretic,
an ACE inhibitor and a beta-blocker.
Table 2 gives the rate of prescription of major
cardiovascular classes according to left ventricular
ejection fraction (LVEF) when available (62% of
patients). ACE inhibitors were more often prescribed when LVEF was reduced (79.0% when LVEF
<40 vs 63.2% when LVEF >40%) as were cardiac
glycosides (42.7 vs 31.3%). Calcium channel blockers were used more commonly in patients with
preserved ejection fraction. The rate of prescription of diuretics and beta-blockers was similar in
the two subgroups.

Agents and dosages

Table 3 gives the type of diuretic agent, ACE inhibitors and beta-blockers used and Table 4 provides
the average daily doses prescribed at hospital
discharge for these three classes.
Loop diuretics were by far the most commonly
prescribed diuretics (94.7% of patients) followed by

spironolactone (23.6% of patients), whereas the use

of thiazide diuretics in this hospital population
was low (11.5% of patients). Furosemide accounted
for 87.7% of all diuretics prescribed and the daily
dosage varied considerably. Fig. 1 gives the distribution of the daily dose of furosemide in the population. Over 40 of patients received 80 mg day1
or more of furosemide. One-third of the patients
received two or more diuretic agents. However,
only 6.6% received the combination of a loop and a
thiazide diuretic, whereas 18.8% received a loop
diuretic and spironolactone.
The rate of prescription of these three first line
CHF medications was studied across the participating countries. It was homogenous for diuretics (data
not shown) (77.8 to 96.4% of patients) but important variations were found for ACE inhibitors and
beta-blockers (Figs 2 and 3 ). The rate of prescription of cardiac glycosides (17.3 to 53.5% of
patients), spironolactone (5.7 to 58.5%), nitrates
(6.3 to 70.6%) varied also widely. Intravenous inotropic therapy was used in 7.2% of our patients,
mostly dopamine (69.4%) and dobutamine (49.1%),
with rates varying widely between centres (0.5 to
19.5%). Calcium channel blockers were used fairly
often (9.8 to 33.4%). Amlodipine (37.9%), verapamil
(22.5%) and diltiazem (20.3%) were the most
common agents.
Table 5 gives the number of different heart
failure medications used 70.6% of the patients were
taking three or more and 44.6% four or more heart
failure medications.

Influence of hospital wards, aetiology and

age
The rate of prescription of ACE inhibitors and betablockers was influenced greatly by the type of
hospital ward to which the patients was admitted.

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Table 3 Names of diuretics, ACE inhibitors and betablockers prescribed. Data shown are percentages of total
prescription in the whole population

Euro Heart Survey

Table 4

467

Daily dosage of the principal diuretics, ACE inhibitors and beta-blockers used in the survey when available

Diuretics (mg day1)

Furosemide
Spironolactone
Toresamide
Amiloride

86.475.2
48.327.8
37.747.6
14.212.7

Beta-blockers (mg day1)

Captopril
Enalapril
Lisinopril
Ramipril
Perindopril

Metoprolol
Atenolol
Carvedilol
Bisoprolol

57.637.1
14.39.1
12.37.8
5.13
3.11

74.943.3
46.927.9
17.616.6
4.72.6

Frequency distribution (in %) for furosemide doses (mg day1).

ACE inhibitors (71.5 vs 56.4% of patients) and betablockers (50.7 vs 26.3% of patients, odds ratio 2.69,
95% confidence interval 2.37 to 3.31) were more
often used in patients receiving care in cardiology
wards compared to general internal medicine
wards (P<0.0001).
However, patients admitted to general internal
medicine wards were older (71.7% of patients were
aged 70 years compared to 46.8% on cardiology
wards, 25.1% difference, 95% CI 23 to 27%) and had
more co-morbidity (83.8 vs 73.8% of patients, 10%
difference, 95% CI 8 to 12%).
ACE inhibitors and beta-blockers were prescribed more commonly in younger patients (67.7%
of those aged <70 years vs 57.9% of those aged 70
years for ACE inhibitors, odds ratio 1.3, 95% CI 1.18
to 1.43); 47.4 of those aged <70 years vs 30% of
those aged 70 years for beta-blockers, odds ratio
1.82, 95% CI 1.63 to 2.04.

The presence of ischaemic heart disease defined

by current/previous myocardial infarction or angina was associated with a higher rate of prescription of beta-blockers (42.1% with vs 22.9% without
IHD, odds ratio 2.63, 95% CI 2.32 to 2.99) and
calcium channel blockers (25% with vs 11% without
IHD, odds ratio 2.56, 95% CI 2.22 to 2.95). Similarly,
the presence of a history of hypertension was
associated with a higher rate of prescription of ACE
inhibitors (69.2% with vs 53.4% without, P<0.0001)
and beta-blockers (40.5% with vs 32.7% without,
P<0.0001).

Role of co-morbidity
The presence of co-morbidity had a powerful influence on the rate of prescription of heart failure
medications. Beta-blockers were prescribed only to

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Fig. 1

ACE inhibitors (mg day1)

468

Euro Heart Survey

Prescription rate of ACE inhibitors (in %) in the different countries participating in the survey.

19.1% of patients with a history of asthma or pulmonary disease as compared to 43.2% to patients
without pulmonary disease, odds ratio 0.35, 95% CI
0.30 to 0.40. Renal dysfunction defined by a serum
creatinine of 176 mol l1 (2 mg dl1) influenced
the rate of prescription of ACE inhibitors (57% in
patients with vs 66.3% in patients without renal
dysfunction) 9.2% difference, 95% CI 4 to 14% (Table
6 ). There was no obvious difference in the average
daily dosage of the most commonly prescribed ACE
inhibitors according to renal function (Table 7 ).
Renal dysfunction also influenced the rate of prescription of spironolactone (15.6% with vs 22% without, difference, 6.4, 95% CI 10 to 2%). However,
the effect of renal dysfunction on the use of ACE
inhibitors and spironolactone disappeared in a
multivariate analysis (see below) suggesting that
other factors associated with renal dysfunction
may have had an important effect on prescribing
patterns.
ACE inhibitors were more commonly prescribed
in diabetic patients (67.6 vs 59.7%, 7.9% difference,
95% CI 6 to 10%) whereas beta-blockers were not
(36.6 vs 36.9%). Both beta-blockers (24.8 vs 37.2%)
and ACE inhibitors (49.6 vs 62%) were less likely to
be prescribed in patients with a recent history of
stroke.
Antithrombotic therapy, either an antiplatelet
or anticoagulant agent, was used in 77.6% of the

patients (ranging from 57.7 to 92.7% in

different countries). The rate of prescription was
influenced by the presence of atrial fibrillation/
supraventricular tachycardia (82.7 with vs 74%
without, odds ratio 2.86, 95% CI 2.41 to 3.39) and
the presence of ischaemic heart disease (82.3 with
vs 65.2% without, odds ratio 2.96, 95% CI 2.51 to
3.50). The average daily dosage of aspirin was
11457 mg.
Anticoagulant therapy was more likely to be
prescribed in the presence of AF/SVT (59.4%)
than in the absence of arrhythmia (33.4%, 22%
difference, 95% CI 20 to 24%).
Digitalis glycosides were more likely to be used
in the presence of atrial fibrillation or supraventricular tachycardia (56.2 with vs 20.9% without, odds ratio 5.50, 95% CI 5.02 to 6.03).

Multivariate analysis (Table 8 )

Beta-blockers
In a multivariate model, the odds of the patient
receiving a beta-blocker were increased if the
admission was to a cardiology ward rather than a
general ward (odds ratio 2.69, 95% CI 1.05 to 1.29)
and were also independently increased for patients
suffering from ischaemic heart disease (odds ratio
2.63, 95% CI 2.32 to 2.99). Odds were decreased in
the presence of respiratory/pulmonary disease

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Fig. 2

Euro Heart Survey

469

Prescription rate of beta-blockers (in %) in the different countries in the survey.

Table 5 Number of cardiovascular medications used at

baseline (among diuretics, ACE inhibitors, beta-blockers,
nitrates, cardiac glycosides, calcium channel blockers,
spironolactone or angiotensin II receptor antagonists)
Number of drugs

1
2
3
4
5

9.8
18.3
26.0
24.5
20.1

(odds ratio 0.35, 95% CI 0.30 to 0.40) and for

patients aged 70 (odds ratio 0.55, 95% CI 0.49 to
0.61).
ACE inhibitors
A multivariate model for ACE inhibitor treatment
showed that the odds of receiving an ACE inhibitor
were increased for male patients (odds ratio 1.34,
95% CI 1.22 to 1.48) and for patients with ischaemic
heart disease (odds ratio 2.35, 95% CI 2.21 to 2.71).
Older patients (over 70 years of age) had reduced
odds of ACE inhibitor treatment (odds ratio 0.77,
95% CI 0.70 to 0.85) (Table 8). Univariate factors

Table 6

ACE inhibitor use according to comorbidity

Age >70 years

Age 70 years
Diabetes
yes
no
Ischaemic heart disease
yes
no
Stroke
yes
no
Renal dysfunction
yes
no
Any of previous
yes
no

P value

67.7
57.9

<0.0001

67.6
59.7

<0.0001

67.7
46.1

<0.0001

49.6
62

<0.0001

57
66.3

<0.0001

62
58

=0.026

including renal dysfunction, diabetes, respiratory

disease influenced the outcome of whether the
patient received an ACE inhibitor. However, when
variables were considered together the effects of
these particular factors did not account for any
additional variation in the results and so were not
included in the final model.

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Fig. 3

470

Euro Heart Survey

Table 7 Average daily doses of ACE inhibitors according

to presence/absence of renal dysfunction. Daily dose
(mg day1, meanSD)
ACE inhibitor

Renal dysfunction

No renal dysfunction

Captopril
Enalapril
Ramipril

52.134.7
13.58.6
4.83.1

58.537.7
14.29
52.9

Calcium channel blockers

Men were less likely than women to receive calcium
channel blockers (odds ratio 0.79, 95% CI 0.71 to
0.88) and the odds were also reduced for patients
admitted to cardiology wards rather than general
internal medicine wards (odds ratio 0.88, 95% CI
0.78 to 0.99). The odds of receiving calcium
channel blockers were independently increased for
patients with ischaemic heart disease (odds ratio
2.56, 95% CI 2.22 to 2.95).
Antithrombotics and aspirin
The odds of a patient receiving an antithrombotic
agent (including aspirin) were increased by the
presence of SVT/AF (odds ratio 2.86, 95% CI 2.41 to
3.39) and by the presence of ischaemic heart disease (odds ratio 2.96, 95% CI 2.51 to 3.50). The odds
for male patients were independently higher than
for female patients (odds ratio 1.19, 95% CI 1.00 to
1.40) but were decreased for patients over the age
of 70 (odds ratio 0.80, 95% CI 0.72 to 0.89). Men
with ischaemic heart disease were more likely to
receive an antithrombotic agent (odds ratio 1.37,

Discussion
Categories of medication
Previous surveys suggest that guidelines for the
pharmacological treatment of chronic heart failure
are not closely adhered to.46 This survey suggests
that although prescription of ACE inhibitors and
beta-blockers may be increasing, they still remain
underused, both in terms of the proportion of
patients receiving them and the doses employed.
This applies particularly to beta-blockers. Only 17%
of our population received the recommended triple
association: diuretic, ACE inhibitor, beta-blocker.
The experience described in this survey reflects
recommendations from Guidelines published in
1997,9 as well as new knowledge obtained during
19972001 expressed in the more recent version
from 2001.
In the EPICAL study, which gathered information
on hospitalization in patients with severe heart
failure due to left ventricular systolic dysfunction
during 1995 in Eastern France, 75% of patients were
receiving ACE inhibitors but only 5% beta-blockers
at discharge.10 The patient population was younger
than patients enrolled in our survey and consisted
mainly of males. The IMPROVEMENT of Heart Failure survey enrolled >10 000 patients in primary
care in 14 European countries during 1999. The
composition of this population, in terms of age,
gender, and left ventricular systolic dysfunction,
was remarkably similar to the current survey, reflecting the high rates of hospitalization amongst
patients with heart failure. In the IMPROVEMENT
survey, 60% of patients were prescribed an ACE
inhibitor, 30% a beta-blocker and 12% spironolactone.11 In a large survey of patients hospitalized

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Spironolactone
In a multivariate model, the odds of the patient
receiving spironolactone were increased if the admission was to a cardiology ward rather than a
general ward (odds ratio 1.61, 95% CI 1.31 to 1.99),
for male patients compared with female patients
(odds ratio 1.28, 95% CI 1.15 to 1.43) and were also
independently increased for patients suffering
from supraventricular tachycardia or arrhythmia
(odds ratio 1.39, 95% CI 1.25 to 1.56). Odds were
decreased in the presence of ischaemic heart disease (odds ratio 0.78, 95% CI 0.66 to 0.92), for
patients aged 70 and over (odds ratio 0.76, 95% CI
0.67 to 0.85) and for those who had suffered a
stroke.
Patients with ischaemic heart disease who had
been admitted to cardiology wards were less likely
to receive spironolactone (odds ratio 0.68, 95% CI
0.54 to 0.87) but more likely to receive spironolactone if they had also had a stroke (odds ratio
5.31, 95% CI 1.13 to 25.05).

95% CI 1.12 to 1.69). Patients with ischaemic heart

disease were less likely to receive antithrombotic
therapy if they also had SVT/AF (odds ratio 0.52,
95% CI 0.42 to 0.64) (Table 8).
An analysis of factors predicting treatment with
aspirin showed that odds were increased for patients aged over 70 years (odds ratio 1.92, 95% CI
1.57 to 2.34) and for male patients (odds ratio 1.34,
95% CI 1.23 to 1.46). Patients with ischaemic heart
disease had higher odds of receiving aspirin (odds
ratio 5.67, 95% CI 4.78 to 6.72) especially if they
were men (odds ratio 1.66, 95% CI 1.39 to 1.99).
The presence of SVT/AF reduced the odds of treatment with aspirin both in isolation (odds ratio 0.44,
95% CI 0.38 to 0.51) and further in combination with
ischaemic heart disease (odds ratio 0.44, 95% CI
0.36 to 0.54.

Euro Heart Survey

Table 8

471

Modelling analysis of the prescription of treatment. In all tables, results are presented as OR95% CI
Odds ratio (95% CI)

Beta-blockers
Factor
Respiratory/pulmonary disease
Speciality at admission (Cardiology vs GIM, for being Cardiology)
IHD
Age group (>70)
Gender (being male)
Cardiac glycosides
Factor
SVT/AF
Calcium channel blockers
Factor
IHD
Gender (being male)
Speciality at admission (cardiology vs GIM, for being Cardiology)
Antithrombotic agents
Factor
Age (>70)
Gender (being male)
SVT/AF
IHD
IHD*Gender
IHD*SVT/AF
ACEi
Factor
Age (>70)
Gender (being male)
IHD
Spironolactone
Factor
Age group (>70)
Speciality at admission (Cardiology vs GIM, for being Cardiology)
IHD
SVT/AF
Gender (being male)
Stroke
Speciality at admission *IHD
Stroke *IHD
Aspirin
Factor
Age (>70)
Gender (being male)
SVT/AF
IHD
IHD*Gender
IHD*SVT/AF

0.35 (0.30 to 0.40)

2.69 (2.37 to 3.31)
2.63 (2.32 to 2.99)
0.55 (0.49 to 0.61)
1.16 (1.05 to 1.29)

5.50 (5.02 to 6.03)

2.56 (2.22 to 2.95)

0.79 (0.71 to 0.88)
0.88 (0.78 to 0.99)

(0.72
(1.00
(2.41
(2.51
(1.12
(0.42

to
to
to
to
to
to

0.89)
1.40)
3.39)
3.50)
1.69)
0.64)

0.77 (0.70 to 0.85)

1.34 (1.22 to 1.48)
2.45 (2.21 to 2.71)

0.76 (0.67 to 0.85)

1.61 (1.31 to 1.99)
0.78 (0.66 to 0.92)
1.39 (1.25 to 1.56)
1.28 (1.15 to 1.43)
0.10 (0.02 to 0.45)
0.68 (0.54 to 0.87)
5.31 (1.13 to 25.05)

1.92
1.34
0.44
5.67
1.66
0.44

(1.57
(1.23
(0.38
(4.78
(1.39
(0.36

to
to
to
to
to
to

2.34)
1.46)
0.51)
6.72)
1.99)
0.54)

SVT=supraventricular tachycardia; AF=atrial fibrillation; IHD=ischaemic heart disease.

for chronic heart failure in cardiology, general

medicine and geriatric departments in France, only
49 and 11% of patients received an ACE inhibitor
and a beta-blocker respectively on admission.4
Similar trends were found in two recent surveys in
Australia and France.5,12 In the Australian study,
58.1% of patients only were receiving ACE inhibitors
and 12% beta-blockers. In the French survey performed among ambulatory patients in private practice, the respective numbers were 54 and 11%.
However, most of these surveys included relatively

small numbers of patients (5001000) and were

performed on a national basis. The Euro Heart
Survey on heart failure is the first pan-European
Survey in hospitalized patients.
Diuretics and particularly loop diuretics were by
far the most commonly used heart failure medications in this survey. Although entry criteria may
have influenced the results, our findings are in
agreement with previous surveys.46,12 There was
little variation from one centre to the other in the
rate of prescription of diuretics. This finding

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0.80
1.19
2.86
2.96
1.37
0.52

472

1. Underestimation of the morbidity and mortality

of the syndrome.
2. Underestimation of the magnitude of the benefit brought about by these classes.13
3. Concern on the potential adverse reactions. For
instance, in a survey among UK general practitioners, nearly half of the participants expressed concern about adverse effects related
to initiation of ACE inhibitors.14 However, our
survey was not designed to study the reasons for
non-prescription of recommended drugs.
4. The clinical profile of the patient: in our survey,
the likelihood of receiving an ACE inhibitor or a
beta-blocker was dependent on the age of the
patients. Patients aged 70 years were less
likely to receive either class of agent. Comorbidities, such as asthma or pulmonary disease reduced the prescription of beta-blockers.
Other co-morbidities, such as diabetes led to
increased usage of ACE inhibitors. Both classes
of drugs were less commonly used in the
setting of a recent stroke but this survey was
prior to the publication of the PROGRESS study,
which suggested a beneficial effect of tight
blood pressure control in patients with stroke.15
Similarly, the rate of utilization of antithrombotic agents and cardiac glycosides
was significantly increased in the presence
of atrial fibrillation or supraventricular
tachycardia.
5. The aetiology of chronic heart failure: the
presence of ischaemic heart disease increased
the rate of prescription of aspirin and betablockers. Both ACE inhibitors and beta-blockers
were used more frequently in hypertensive
patients.
6. Speciality at admission: the medical specialty
responsible for patient care influenced the rate

of prescription of recommended drugs. In our

survey, both drugs were significantly more prescribed in cardiology wards than it internal
medicine wards, although this may have more
to do with the greater age and co-morbidity
of patients cared for in medical wards. In a
Germany study, it was shown that both ACE
inhibitors and beta-blockers were less prescribed in a rural than in a metropolitan hospitals potentially reflecting the benefits of
specialization.6
7. The pathophysiology of heart failure: many
patients in the Euro Heart Failure survey had
preserved left ventricular systolic function, a
condition for which there is little evidence that
treatment alters outcome. ESC guidelines indicate that recommendations are largely speculative. The results of several large randomized
trials are awaited.16 The high proportion of
patients with diastolic dysfunctionoften
due to hypertensionnot only help explain the
underuse of beta-blockers and ACE inhibitors
but also the high rate of use of calcium channel
blockers which are not recommended or contraindicated for the treatment of heart failure
with systolic dysfunction.
Treatment directed at ischaemic heart disease,
rather than at heart failure, probably explains why
the prescription of beta-blockers was not even
lower and also explains the high rate of use of
calcium channel blockers and nitrates, agents for
which there is little evidence of benefit in
patients with left ventricular systolic dysfunction.
Spironolactone was prescribed in more than 20% of
our overall population and even more commonly
in the absence of renal dysfunction, suggesting
that the conclusions of the RALES study have been
accepted in Europe.17 Angiotensin II receptor
antagonists were used only in a minority of
patients, reflecting uncertainty over the role of
these agents as an alternative or in addition to
ACE inhibitors.18,19 ESC guidelines do not advise
the use of this class of drugs as first line
therapy.
Cardiac glycosides, an old fashioned heart failure medication which has only been demonstrated
to reduce the rate of hospitalizations for patients in
sinus rhythm20 but which may continue to have a
role for patients with atrial fibrillation was still
used in about a third of our population, including
21% of those without supraventricular arrhythmia.
In most ESC countries, more patients with heart
failure now receive beta-blockers than receive
digoxin.

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contrasts with the important variations found in the

rate of prescription of both ACE inhibitors and
beta-blockers. However, it should be emphasized
that these variations are individual centre variations and therefore only partly reflect the current
situation in ordinary practice in a given country. It
is likely that variation between centres within each
country are also large.
The rate of prescription of ACE inhibitors
reached 80% in patients with documented reduction in ejection fraction, which indicates that
the situation is improving as compared to previous
surveys. In contrast, beta-blockers were clearly
under-prescribed even in patients with a
documented low ejection fraction.
Various factors can explain the under use of ACE
inhibitors and beta-blockers:

Euro Heart Survey

Euro Heart Survey

Dosage and preparations

Limitations
We acknowledge that Euro Heart Survey on Heart
Failure was concentrated on University hospitals
clustered with one or more community hospitals.
This design might have resulted in an over representation of metropolitan hospitals vs rural healthcare units. Therefore, the Euro Heart Survey on
Heart Failure is not a true epidemiological survey

representative of the overall population but rather

a large hospital-based European data base.

In summary
We report here the detailed analysis of treatments
used in the Euro Heart Survey on Heart Failure.
Diuretics were the most commonly prescribed class
of agent. Overall, ACE inhibitors were used in 61%
of patients and almost 80% of those with reduced
left ventricular ejection fraction. The respective
figures for beta-blockers were less widely used
overall (37%) and in patients with reduced left
ventricular ejection fraction (49%). Daily dosages
of ACE inhibitors reached 5060% of the target
recommended dose except for captopril, which was
prescribed at much lower doses, whereas the daily
dosage of beta-blockers were far below the target
dose used in randomized trials.
Many factors including age, aetiology of heart
failure, co-morbidity, specialty at discharge and
pathophysiology of heart failure influenced the rate
of prescription of the recommended drugs. Overall,
our results suggest that the situation is improving
for ACE-inhibitor prescription but remains suboptimal for beta-blockers. Continued medical education and improved organisation of services are
required to improve the dissemination and uptake
of guidelines on treatment of chronic heart failure
in daily practice.

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Euro Heart Survey