Patterns Of Contraindications And Initiation Of Guideline-Directed Medical Therapy Among Older Adults With Heart Failure, With And Without Polypharmacy

Abstract

<h3>Introduction</h3> Underprescribing of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) remains a problem. Whether polypharmacy contributes to underprescribing is unknown. Hypothesis: We hypothesized that patients with polypharmacy would have lower rates of GDMT initiation compared to those without polypharmacy. <h3>Methods</h3> We examined Medicare beneficiaries aged ≥65 years hospitalized for HFrEF between 2003-2017 from REGARDS (Reasons for Geographic and Racial Difference in Stroke). We compared % with contraindications to GDMT, % eligible for GDMT-initiation during hospitalization, and % initiation of eligible indicated GDMT prior to discharge among those with and without polypharmacy. Polypharmacy was defined as ≥10 standing medications at admission. We examined the neurohormonal antagonists among all patients with HFrEF, anticoagulation among those with atrial fibrillation, and antiplatelet agents and statins among those with coronary artery disease. <h3>Results</h3> There were 334 participants included in this study. The mean age was 78 years, 38% were women, and 33% were Black. Polypharmacy was present among 43% of patients. Coronary artery disease was present in 78% of patients and 40% of patients had atrial fibrillation. Patients with polypharmacy had a lower prevalence of contraindications to neurohormonal antagonists, and a higher prevalence of contraindications to anticoagulation, antiplatelet agents, and statins. Those with polypharmacy had lower % initiation of eligible indicated GDMT (without contraindications) prior to discharge (Table 1). <h3>Conclusion</h3> Among patients with HFrEF, initiation of eligible indicated GDMT prior to discharge occurs less frequently in patients with polypharmacy compared to those without polypharmacy even after accounting for contraindications. Unique strategies are needed to optimize GDMT among patients with HFrEF and polypharmacy.