Abstract 10316: De-escalation of Guideline-Directed Medical Therapy in Ambulatory Heart Failure: Insights from the EPIC-HF Trial

Abstract

Background: Despite proven benefits of guideline directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF), multiple studies have shown that rates of GDMT prescribing are suboptimal worldwide. The recently completed EPIC-HF trial demonstrated that a pre-clinic patient activation tool significantly increased GDMT intensification following a visit with a cardiology provider. However, whether GDMT intensification was sustained or associated with subsequent de-escalation was unknown. Methods: The EPIC-HF trial reported GDMT intensification at 1 month follow-up after the initial clinic visit. We analyzed GDMT prescription data from 1 to 6 month follow-up to examine the effect of an initial GDMT intensification by 1 month on subsequent rates of GDMT de-escalation from 1 to 6 months. Results: A total of 282 patients completed 6 month follow-up. From the study visit to 1 month follow-up, 39.7% (n=112) had an initial GDMT intensification. An initial intensification was not significantly associated with subsequent de-escalation of any GDMT medication from 1 to 6 month follow-up (24.1% de-escalated after no initial change vs 28.6% after initial intensification, p=0.40), nor was it significantly associated with de-escalation of any individual class of medication (BB 8.8% vs 11.6%, p=0.44; ACE-I 5.9% vs 8.9%, p=0.33; ARB 5.3% vs 6.3% p=0.73; MRA 6.5% vs 8.0%, p=0.62). Initial GDMT intensification was associated with dose reduction or discontinuation of loop diuretic (4.1% vs. 11.6%, p=0.02). Conclusions: Patients who had GDMT intensified at an initial visit were not significantly more likely to have a subsequent de-escalation by 6 month follow-up; however, they were more likely to have their loop diuretic down-titrated or discontinued.