Has the use of concomitant cardiac medications improved over time in primary prevention ICD patients? Insights from the APPRAISE ATP study

Abstract

Abstract Introduction Patients (pts) implanted with an ICD for a primary prevention (PP) typically receive concomitant medications (meds) to treat LV dysfunction. However, It is not well established whether compliance with guideline-directed medical therapy (GDMT) has improved over time in this population. Methods Data were drawn from the MADIT-RIT (2009-2012) and APPRAISE ATP (2016-present) studies. Both studies were global in scope and enrolled pts who were implanted with an ICD for PP indications. Meds prescribed at baseline were compared between the two studies. Meds of interest included: evidence-based beta blockers [(BB-EV) defined as carvedilol, metoprolol, and bisoprolol], ACE inhibitors, ARBs, ARNIs, and mineralocorticoid receptor antagonists (MRA). SGLT2i were introduced into GDMT after the study APPRAISE ATP started and were not included. Meds were analyzed both individually and in combination as GDMT, defined as joint use of BB-EV, ACE/ARB/ARNI, and MRA. Differences were compared with a t-test for continuous variables, a Chi-square test for categorical data and a Cochran-Armitage trend test for ordinal categorical data. Results Demographics for the two studies were compared for pts who received ICDs in MADIT-RIT (n=742) and APPRAISE ATP (n=2627 enrolled with n=2596 randomized) and are shown in the table below. When compared to MADIT-RIT, APPRAISE ATP pts were significantly older with a greater prevalence of diabetes. Comparison of baseline meds are shown in both the table and in the figure. Although BB-EV and ACE/ARB use was slightly but significantly lower in APPRAISE ATP, these declines were offset by a significant increase in MRA use in APPRAISE ATP. A marked shift was seen over time with significant decline in use of ACE-I that was matched by a significant increase in use of ARBs, either alone or in combination with ARNIs. When considering meds used in combination for GDMT, pts in APPRAISE ATP were significantly more likely to meet GDMT recommendations than pts who were enrolled in MADIT-RIT (36.7% vs 27.2%, respectively, p<0.001). Conclusions In the APPRAISE ATP study, compliance with GDMT in PP ICD pts has significantly improved when compared to the MADIT-RIT study conducted 10 years previously. These changes have been characterized by greater use of MRAs as well as a shift away from ACE inhibitors towards use of ARBs and ARNIs. Although there was considerably greater compliance with GDMT, with approximately one third of pts fulfilling GMDT, opportunities still remain for improvement. Further investigation is needed to determine what influence greater compliance with GDMT may have on improved clinical outcomes such as reductions in VT/VF event rates and all-cause mortality.