Gaps in Medical and Device Therapy for Patients with Left Ventricular Systolic Dysfunction: The EchoGap Study

Hisham Dokainish*, Lauren Jewett, Robby Nieuwlaat, Joshua Coulson, Catherine Demers, Eva Lonn, Jeff Healey, Brian Haynes , Stuart Connolly
Division of Cardiology, Department of Medicine and the *Department of Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada

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© Dokainish et al.; Licensee Bentham Open.

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

* Address correspondence to this author at the Department of Epidemiology and Biostatistics McMaster University, Echocardiography, Hamilton Health Sciences, 237 Barton St. E. CVSRI #C3 111, Hamilton, ON, Canada L8L 2X2; Tel: 905-527-4322; Ext: 40327; Fax: 1-905-577-1424; E-mail:



To assess gaps between guidelines and medicine prescription/dosing and referral for defibrillator therapy in patients with left ventricular systolic dysfunction (LVSD).


Outpatient echocardiography reports at an academic hospital centre were screened and outpatients with LVEF<40% were included. A questionnaire was mailed to the patients’ physician, querying prescription/dosing of ACE-inhibitors (ACEi), angiotensin receptor blockers (ARB) and beta-blockers (BB). Patients with LVEF<30% had additional questions on implantable cardiac defibrillator (ICD) referral.


Mean age was 69.6+/-12.2 years and mean LVEF was 29.7+/-6.5%. ACEi and/or ARB prescription rate was 260/309(84.1%) versus 256/308(83.1%) for BB (p=NS for comparison). Of patients on ACEi, 77/183(42.1%) were on target dose, compared to 7/45(15.5%) for ARB and 9/254(3.5%) for BB (p<0.01). Of 171/309 patients (55.3%) with LVEF<30%, 72/171(42.1%) had an ICD and 16/171(9.4%) were referred for one.


Prescription rates of evidence-based HF medicines are relatively high in outpatients with LVSD referred for echocardiography at this Canadian academic medical centre; however, the proportion of patients at target doses was modest for ACEi and low for ARB and BB. Approximately half of patients who qualify for ICD by EF alone have one or were referred. Important reasons for patients with LVSD not on evidence-based therapy were identified.

Keywords: Echocardiography, Evidence-based Medicine, Left Ventricular Dysfunction, Heart Failure, Knowledge Translation, Treatment Gaps..