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Primum non nocere: the dangers of deferring heart failure therapy

The physician’s duty of primum non nocere, or avoiding harm to patients, is a central component of clinical care according to the Hippocratic Oath. In this issue of the Journal, Zaman et al.1 describe a smart and innovative way of addressing the very longstanding need among physicians to find an individualized balance between harm and benefit with regard to three specific issues, namely, the under-treatment of patients with chronic heart failure (CHF), the extent of the information on very low procedural risk provided in patient informed consent forms, and the subjective opinion of the respective physician. Chronic heart failure is a global health problem that imposes increasing burdens on health care systems and, most importantly, is characterized by high rates of mortality and morbidity.2 Guideline-recommended therapies3 are incompletely implemented in the treatment of CHF patients, which indicates a certain degree of inertia in physicians when it comes to prescribing appropriate drugs and doses.4 However, patients are often reluctant to take drugs. Poor adherence is associated with ageing, the presence of co-morbidities and health care illiteracy,5 and leads to a worsening of outcomes that is usually greater than the beneficial effect of new contemporary treatments.6 Thus, poor adherence can result from poor compliance on the part of physicians in following guideline recommendations and poor compliance on the part of patients in following their physicians’ advice. Zaman et al.1 should be applauded for developing an interesting idea and presenting a novel way of examining improvement in the implementation of various therapies. The investigators analysed randomized controlled trials of CHF treatment and evaluated the outcomes of patients treated with angiotensin-converting enzyme inhibitors, beta-blockers and aldosterone antagonists, as well as combinations thereof. By using mortality data from control groups,