Patient Perspectives on a Polypill Strategy for Heart Failure with Reduced Ejection Fraction: A Convergent-Parallel Mixed Methods Study Embedded in a Randomized Clinical Trial.

Background: The benefit of guideline directed medical therapy (GDMT) in heart failure with reduced ejection fraction (HFrEF) is well established in the medical literature and clinical practice guidelines. The low prevalence of optimal dosing of these medications remains an obstacle in providing quality care for this patient population. Methods: An electronic medical record (EMR) triggered alert was attached to all patient charts with ICD-10 codes associated with HFrEF at a single internal medicine residency-associated outpatient primary care office. This alert urged use of a GDMT initiation and titration reference sheet based on the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction . A retrospective review of patients with corresponding ICD-10 codes and documented ejection fractions less than or equal to 40% was conducted and the intensity of GDMT dosing in these patients was recorded. A group of patients treated 3 years prior to the intervention were then compared to those treated after the intervention Results: 38 patients with a documented diagnosis of HFrEF that were evaluated between January 9, 2017 and January 9, 2020 were identified. 32 (84.2%) of these patients were on GDMT beta blockers and only 1 (3.1%) of these patients were receiving the target dose. Of the 31 (81.5%) of patients receiving ACE/ARB/ARNi therapy, 9 (41.9%) patients received target dosing. Mineralocorticoid receptor antagonist therapy (MRA) was prescribed to 11 (28.9%) patients; all of these patients received the target dose. Uptitration of medication was observed in the management of 9 (23.7%) of patients. Following the intervention, 8 patients with a documented diagnosis of HFrEF were evaluated between January 9, 2020 and March 5, 2020.GDMT beta blockers were prescribed to 7 (87.5%) of these patients; 1 (12.5%) patient received a target dose. ACE/ARB/ARNi therapy was given to all 8 patients and half of the patients were prescribed a target dose. MRA treatment was given to 2 (25%) of the8 patients; both patients were given the target dose. Uptitration of GDMT was observed in 1 (12.5%) patient following the intervention. There was no statistically significant difference between pre-intervention and post-intervention groups (P= 0.7187) regarding initiation and uptitration of GDMT. Conclusion: An EMR triggered effort to improve GDMT dosing in HFrEF patients did not show significant improvement in a small patient population over a short time period.

Electronic Alerts to Improve Heart Failure Therapy in Outpatient Practice: A Cluster Randomized Trial

Pharmacist Intervention Increases Optimization Of Guideline-directed Medical Therapy In Heart Failure Patients With Medication Intolerances

Introduction: Current research suggests racial differences exist in the utilization of guideline directed medical therapy (GDMT) and prognosis in heart failure with reduced ejection fraction (HFrEF). Whether individual and community level socioeconomic status (SES) impacts prescription patterns of GDMT and prognosis in HFrEF has not been studied. Methods: We studied 669 ARIC participants with incident HFrEF (EF<50%) (mean age 77.6 (SD 6.5) years; 39% black; 46% women) during 2005-2017 (median 1.8 years of follow-up). We assessed the proportion of patients on optimal GDMT (defined as ß-blockers [BB] and ACE inhibitors [ACEI] or angiotensin receptor blockers [ARB]) or adequate GDMT (one of either BB, ACEI/ARB, aldosterone antagonists [AA], or hydralazine and nitrates [H-ISDN]) at hospital discharge by individual SES (education and income), neighborhood SES (area deprivation index: ADI) and their combination (Table). We also examined the contribution of GDMT prescription to prognosis overall, and by SES. Subsequently, we quantified the association of SES with mortality and re-hospitalization for HFrEF. Results: The proportion of patients prescribed optimal and adequate GDMT was 54% and 81%, respectively. BB were most frequently prescribed (83%), followed by ACEI/ARB (61%), AA (11%), and H-ISDN (9%). Overall, BB were associated with lower mortality, while H-ISDN were associated with higher mortality, compared to their non-use counterparts. ACEI/ARB were associated with lower re-hospitalization, compared to non-users of ACEI/ARB. The prescription of GDMT and the effect of GDMT on prognosis did not significantly differ by SES. Despite that, lower SES was independently associated with higher risk of mortality and re-hospitalization (Table). Conclusions: Overall, optimal GDMT was low at discharge, but did not differ by SES. Despite that, there were significant differences in death and re-hospitalization by SES, suggesting a potential need for tailored approaches to HFrEF management for low SES individuals.

Validation Of A Computable Algorithm For Medication Optimization In Heart Failure With Reduced Ejection Fraction

Background: Hospitalizations for heart failure with reduced ejection fraction (HFrEF) represent key opportunities to optimize guideline-directed medical therapy (GDMT). We sought to determine contemporary GDMT prescribing patterns following HFrEF hospitalization in the Veterans Health Administration (VA). Methods: National retrospective cohort study of electronic health records from VA. We included adults hospitalized with a primary diagnosis of HFrEF between 2022-2023 who were discharged home. Optimal GDMT was defined as treatment with four classes (beta-blockers, BB, renin-angiotensin-aldosterone system inhibitors, RAASi, mineralocorticoid receptor antagonists, MRA, and sodium glucose-like transporter 2 inhibitors, SGLT2i). We identified GDMT present on admission and GDMT initiated in hospital or within 7 days of discharge to determine (1) if the number of GDMT classes was intensified and (2) if optimal GDMT was received. Among those admitted on suboptimal GDMT, we used multivariable logistic regression to examine the association of five key sociodemographic domains (age, sex, race and ethnicity, rurality, and neighborhood resource deprivation) with GDMT use controlling for clinical and facility-level factors. Results: The cohort included 20,866 HFrEF hospitalizations (60% aged ≥70 years, 2% female, 48% White, 38% Black, 39% rural). The proportion of patients on optimal GDMT increased from 12% on admission to 29% on discharge. Of those on suboptimal GDMT on admission, 56% intensified GDMT and 29% initiated ≥2 new GDMT classes. At admission, 67%, 55%, 28%, and 32% were using BBs, RAASis, MRAs, and SGLT2is, respectively (Figure 1). At discharge, GDMT use increased to a total of 92%, 78%, 47%, and 56%, respectively. Older patients were less likely to intensify GDMT (Figure 2) or receive optimal GDMT (Figure 3) at discharge. There were no differences in GDMT use by sex, race or ethnicity. Patients residing in rural areas were less likely to receive GDMT intensification (OR: 0.86; 95% CI, 0.78 to 0.92) and optimization (OR: 0.78; 95% CI, 0.71 to 0.86). Patients living in neighborhoods with fewer resources were less likely to receive optimal GDMT, but had similar rates of GDMT intensification. Conclusions: Among Veterans hospitalized for HFrEF only a third received optimal GDMT while over half intensified GDMT at discharge. Disparities in GDMT initiation at discharge by age, rurality, and neighborhood highlight opportunities for targeted quality improvement efforts.

Acute Heart failure (AHF) is among the most frequent causes of hospitalization in the United States, contributing to substantial health care costs, morbidity, and mortality. Inpatient initiation of guideline-directed medical therapy (GDMT) is recommended for patients with heart failure with reduced ejection fraction (HFrEF) to reduce the risk of cardiovascular death or HF hospitalization. However, underutilization of GDMT prior to discharge is pervasive, representing a valuable missed opportunity to optimize evidence-based care. The PRagmatic Trial Of Messaging to Providers about Treatment of Acute Heart Failure tests the effectiveness of an electronic health record embedded clinical decision support system that informs providers during hospital management about indicated but not yet prescribed GDMT for eligible AHF patients with HFrEF. PRagmatic Trial Of Messaging to Providers about Treatment of Acute Heart Failureis an open-label, multicenter, pragmatic randomized controlled trial of 1,012 patients hospitalized with HFrEF. Eligible patients randomized to the intervention group are exposed to a tailored best practice advisory embedded within the electronic health record that alerts providers to prescribe omitted GDMT. The primary outcome is an increase in the proportion of additional GDMT medication classes prescribed at the time of discharge compared to those in the usual care arm.

Guideline-Directed Medical Management of Heart Failure with Reduced Ejection Fraction: Improved Outcomes With Quadruple Therapy

Heart failure treatment and the art of medical decision making.

Guideline-directed medical therapy (GDMT), including angiotensin receptor-neprilysin inhibitor, angiotensin-converting enzyme inhibitors, beta blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors, has significantly improved outcomes in patients with heart failure with reduced ejection fraction (HFrEF). We examined whether modern GDMT alters the historically observed parity in mortality between HF and cancer. From the TriNetX Global Collaborative Research Network (2015-2024), we identified 32 125 patients with HFrEF on GDMT (angiotensin receptor-neprilysin inhibitor or angiotensin-converting enzyme inhibitors, mineralocorticoid receptor antagonists, beta blockers, and sodium-glucose cotransporter-2 inhibitors), 403 389 not on full GDMT (not receiving all 4 drugs concurrently), and 2 481 106 with malignant cancers. All-cause mortality was compared between HFrEF and cancer overall and across the most common cancers in men (prostate, colorectal, lung) and women (breast, lung, colorectal) using propensity score matching. Patients with HFrEF on GDMT with angiotensin receptor-neprilysin inhibitors had significantly better survival than patients with cancer (hazard ratio [HR], 0.44 [95% CI, 0.41-0.47]; P<0.001). A survival benefit, though less pronounced, was also seen for GDMT with angiotensin-converting enzyme inhibitors instead of angiotensin receptor-neprilysin inhibitor (HR, 0.62 [95% CI, 0.57-0.69]; P<0.001). Patients not on GDMT had higher mortality than patients with cancer (HR, 1.15 [95% CI, 1.13-1.17]; P<0.001). Among the most common sex-specific cancers, only patients with prostate and breast cancer had better survival than those with HFrEF on GDMT, whereas patients not on GDMT showed worse outcomes across most cancers, except lung cancer. In this large real-world analysis, patients with HFrEF on GDMT showed better survival than those with cancer overall and across most sex-specific cancers. Patients not on GDMT experienced worse outcomes, emphasizing the need to optimize treatment in HFrEF.

BackgroundRandomized clinical trials in populations with heart failure with reduced ejection fraction may not be reflective of the general population with heart failure with reduced ejection fraction. Our study assessed the representativeness of the GALACTIC‐HF (Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure) patient population in Kaiser Permanente Southern California.Methods and ResultsWe identified 9770 patients with a diagnosis of heart failure with reduced ejection fraction from 2014 to 2018 using electronic health records. Four mutually exclusive cohorts were created, including GALACTIC‐HF–ineligible cohorts: (1) not taking guideline‐directed medical therapy (GDMT) and (2) taking GDMT; and GALACTIC‐HF–eligible cohorts with: (3) ejection fraction (EF) ≤28% and (4) EF 29% to 35%. Patients were followed for 30‐day and 1‐year mortality and 30‐day, 180‐day, and 1‐year hospitalization. Overall, 3626 (37.1%) met GALACTIC‐HF inclusion criteria with EF ≤35%, and 2367 (65.3%) of those individuals had EF ≤28%. The risk of 1‐year mortality was lower among all cohorts versus the GALACTIC‐HF–ineligible cohort not taking GDMT (hazard ratio, 0.80 [95% CI, 0.70–0.91], 0.84 [95% CI, 0.72–0.98], and 0.62 [95% CI, 0.51–0.75] for the GALACTIC‐HF–ineligible cohort taking GDMT and GALACTIC‐HF‐eligible cohorts with EF ≤28% and 29%–35%, respectively). Compared with the GALACTIC‐HF–ineligible cohort not taking GDMT, the short‐term hospitalization risk at 30 and 180 days were similar for both GALACTIC‐HF–eligible cohorts and the hospitalization risk at 1 year was similar for the GALACTIC‐HF–eligible cohort with EF ≤28%.ConclusionsA large portion of patients with heart failure with reduced ejection fraction with low EF met inclusion criteria for the GALACTIC‐HF trial and, despite being on GDMT, had hospitalization rates similar to those not taking GDMT, suggesting potential benefits from other innovative treatments.

Medication Trajectory and Treatment Patterns in Medicare Patients With Heart Failure and Reduced Ejection Fraction

Background 2021 European Society of Cardiology quality indicators (QIs) for the care and outcomes of adults contains a domain for patients with heart failure with reduced ejection fraction (HFrEF) for initial treatment of guideline-directed medical therapy (GDMT) which includes beta-blocker (BB), angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-neprilysin receptors inhibitors (ARNI), mineralocorticoid receptor antagonist (MRA), and sodium-glucose transporter-2 inhibitor (SGLT2i). The QIs for the individual GDMT is estimated by finding the proportion of patients with HFrEF who are prescribed each therapy in the absence of any contraindication. Purpose To identify the role of the board certified cardiology pharmacist (BCCP) on improving the quality indicators regarding the prescribing of GDMT among patients with HFrEF during hospitalization and before discharge. Methods A cross-sectional study was conducted at the cardiac care unit in a single heart center in Iraq between January 2021 to February 2023. Among the multidisciplinary team member at this unit is a BCCP who suggests optimization of medical therapy based on the recommendations of updated European or American guidelines for the management of different cardiovascular diseases including HFrEF. The suggestion then discussed with the cardiologists for agreement. The study included the medical records for patients with HFrEF and BCCP interventions whether the interventions regarding GDMT or other medical therapy interventions. Data were reviewed and were analyzed to identify the specific interventions related to the initiation of one or more GDMT in each patients. Results Among 164 patients with HFrEF with BCCP interventions, there were 102 (62%) patients who were eligible for one or more of the GDMTs prescription which was suggested by BCCP. The most GDMT initiated was MRA 53 (43%) among 123 interventions and in 53 (52%) of 102 patients (Figure 1). QIs were improved (100%) for BB, ACEI/ARNI, MRA, and SGLT2i among eligible patients as shown in table 1. Conclusions The role of BCCP is essential among heart team for improving QIs related to the GDMT prescription among patients with HFrEF based on the recommendations of the updated guidelines. BCCP mainly improved the QIs for the prescription of MRA.Frequency of GDMT Initiation by BCCPGDMT Initiation Reflecting Improved QIs

Introduction: Human immunodeficiency virus (HIV) infection increases the risk of heart failure, particularly Heart Failure with Reduced Ejection Fraction (HFrEF). Guideline-directed medical therapy (GDMT), including beta-blockers (BB), renin-angiotensin system inhibitors (RASi), mineralocorticoid receptor antagonists (MRAs), and sodium-glucose cotransporter-2 inhibitors (SGLT2i), has been shown to decrease morbidity and mortality in patients with HFrEF. Hypothesis: Lower GDMT prescription rates would be associated with higher 30-day readmission or mortality rates in patients with HIV and HFrEF Aims: To assess GDMT prescription rates and their impact on short-term morbidity and mortality in patients with HIV and HFrEF. Methods: Patients diagnosed with HIV and HFrEF who were admitted with acute heart failure within Emory Healthcare from 2010 to 2020 were identified using ICD codes. Diagnoses were confirmed by physician review. Baseline demographics, CD4 count, viral load (VL), prescriptions for GDMT and antiretroviral medications at the time of admission were assessed. A simple GDMT score was created, assigning 1 point for each medication prescribed (0-3, excluding SGLT2i given the study timeframe). Multivariable logistic regression was used to determine the association of the GDMT score with 30-day readmission or death, adjusting for age, sex, race, hypertension, diabetes, estimated glomerular filtration rate (eGFR), and VL. Results: The study included 161 patients (mean age 56 years, 22.9% women, 86.3% Black, 55% with VL &lt;200 copies/ml). Of these, 96 (59.6%) were prescribed BB, 82 (50.9%) RASi, and 18 (11.1%) MRA. This distribution resulted in 38 patients (26.7%) with a GDMT score of 0, 62 patients (43.7%) with a score of 1, 49 patients (34.5%) with a score of 2, and 12 patients (8.5%) with a score of 3. During the 30-day follow-up period, 22 patients (13.7%) were re-hospitalized or died. After adjusting for risk factors, a higher GDMT score was associated with a lower risk of 30-day readmission or death (OR 0.24, CI 0.06 – 0.88, p = 0.032). Male sex was also associated with a lower risk of this endpoint (p = 0.045). Conclusion: GDMT is under-prescribed in patients with HIV and HFrEF. Lower rates of GDMT prescription are associated with worse short-term outcomes in this population. Further efforts are required to ascertain reasons for under-prescription in these comorbid patients and to improve adherence to GDMT guidelines to enhance patient outcomes.

Introduction: Guideline-directed medical therapy (GDMT) dramatically improves outcomes in heart failure with reduced ejection fraction (HFrEF). Our goal was to examine GDMT use in community patients with newly diagnosed HFrEF. Methods: We performed a population-based, retrospective cohort study of all Olmsted County, Minnesota residents with newly diagnosed HFrEF (EF≤40%) 2007-2017. We excluded patients with contraindications to medication initiation (allergy, intolerance, heart rate&lt;50 for beta blockers, SBP &lt;80mm Hg for beta blockers, ACEi/ARB/ARNI; high creatinine (&gt;3 mg/dL ACEi/ARB/ARNI, &gt;2.5 men or &gt;2.0 mg/dL women for mineralocorticoid receptor antagonists, MRAs) or hyperkalemia (potassium &gt;5 meQ/L for ACEi/ARB/ARNI, MRA). We examined use and peak dose achieved for beta blockers, HF beta blockers (metoprolol succinate, carvedilol, bisoprolol), ACEi/ARB/ARNI, and MRA in the first year after HFrEF diagnosis. We used logistic regression to evaluate predictors of GDMT use. Results: From 2007-2017, 1160 patients were diagnosed with HFrEF (mean age 69.7 years, 65.6% men). Most eligible patients received beta blockers (92.1%) and ACEi/ARB/ARNI (86.5%) in the first year after HFrEF. However, only 63.6% of patients were treated with a HF beta blocker, and most did not receive MRAs (82.6%). The percentage of treated patients reaching medication target doses was 20.5% for HF beta blockers, 25.3% for ACEi/ARB/ARNI, and 11.2% for MRA. Compared to patients not seen in an HF clinic, patients seen in an HF clinic (n=380, 32.8%) were at greater odds of receiving beta blockers (OR 3.85, 95% CI 1.79-8.33); HF beta blockers (OR 3.85, 95% CI 2.63-5.26); ACEi/ARB/ARNIs (OR 3.85, 95% CI 2.17-6.67); and MRAs (OR 3.03, 95% CI 2.08-4.35). Other independent predictors of GDMT use included younger age (beta blockers, ACEi/ARB/ARNI), male gender (MRAs), higher SBP (beta blockers, ACEi/ARB/ARNI), lower EF (HF beta blockers), higher BMI (MRAs), and diabetes (ACEi/ARB/ARNI, p&lt;0.05 for each). Conclusions: In this population-based study, most patients with newly diagnosed HFrEF received beta blockers and ACEi/ARB/ARNIs, but goal doses were usually not achieved. GDMT use was much higher in patients referred to an HF clinic.