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Évaluation, en conditions de pratique courante, de l’application et de l’efficacité des recommandations européennes dans la prise en charge médicamenteuse de l’insuffisance cardiaque : analyses de la cohorte EPICAL2

Abstract : Heart Failure (HF) is a major and growing public health problem. In order to limit the morbidity and mortality associated with a diagnosis of HF, the European Society of Cardiology (ESC) recommends for the management of HF with reduced ejection fraction (HFREF), angiotensin converting enzyme inhibitor (ACEI) (or angiotensin receptor blocker (ARB) in cases of ACEI intolerance), betablockers (BB), and mineralocorticoid receptor antagonists (MRA). Concerning HF with preserved ejection fraction (HFPEF), the results of randomized trials are not yet conclusive on the efficacy of these drugs, and the recommendations remain very limited and cautious. The objectives of this thesis were to explore HF drug management over three years of follow-up in clinical practice using real-life data, and to evaluate the prognostic impact of this management. This work was built on data from the EPICAL2 cohort, which allowed for the follow-up of patients and consideration of drug prescriptions at several measurement times during follow-up. In a first study, we showed that adherence to ESC recommendations was relatively high but remained suboptimal with around two-thirds of patients receiving recommended medications. Factors related to the patient's clinical condition such as the presence of comorbidities always remain a barrier to the application of these recommendations. The prognostic impact of applying these recommendations was explored in a second study. We demonstrated a significant survival benefit when the recommended medications were prescribed continuously during the follow-up and also when these medications were prescribed discontinuously over time compared to the non-prescription of the recommended drugs. The last study in this work was devoted to the management of patients with HFPEF. We identified five distinct treatment regimens in which BB, IACEI/ARB and MRA are prescribed by physicians in clinical practice in a stable manner over 24 months of follow-up. In addition, analyses showed a significant reduction in total mortality over three years in patients using long-term bitherapy ACEI/ARB and BB, BB alone,ACEI/ARAB alone, or the tritherapy with ACEI/ARB, BB and MRA. In conclusion, our thesis work made it possible to describe the therapeutic practices adopted by clinicians in an HF management context corresponding to clinical practice conditions. We were able to present additional evidence to support the clinical efficacy over time of therapies recommended by ESC in HF patients in a real-life context and suggest that the benefit of introducing the recommended therapies whenever the patient's clinical condition allows it.
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https://hal.univ-lorraine.fr/tel-03254703
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Submitted on : Wednesday, June 9, 2021 - 9:43:31 AM
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  • HAL Id : tel-03254703, version 1

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Sarah Bitar. Évaluation, en conditions de pratique courante, de l’application et de l’efficacité des recommandations européennes dans la prise en charge médicamenteuse de l’insuffisance cardiaque : analyses de la cohorte EPICAL2. Santé publique et épidémiologie. Université de Lorraine, 2020. Français. ⟨NNT : 2020LORR0222⟩. ⟨tel-03254703⟩

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