Reasons for Failure to Optimize Guideline-Directed Medical Therapy for Heart Failure with Reduced Ejection Fraction Patients in Clinical Practice

Abstract

Introduction Although strategies for optimization of pharmacologic therapy in patients with heart failure with reduced ejection fraction (HFrEF) are carefully scripted by guidelines, data from large HF registries suggests that guideline-directed medical therapies (GDMT) are underutilized amongst eligible patients in clinical practice. Whether this discrepancy reflects medication intolerance, perceived contraindications, or a quality of care issue remains unclear. Failure to optimize GDMT in patients with HFrEF is frequently related to provider, rather than patient factors. Methods As part of a quality improvement project, we completed a retrospective review of the electronic health record (EHR) for 194 patients with chronic HF and EF ≤ 40% to document eligibility for four distinct categories of GDMT: ACE inhibitors/Angiotensin Receptor Blockers(ACE-i/ARB), Angiotensin Receptor-Neprilysin Inhibitors (ARNi), beta blockers, and Mineralocorticoid Receptor Antagonists (MRA). Prescription of GDMT and medication dosage in relation to guideline targets were recorded for each category. Reasons for non-prescription of evidence-based therapies and usage of suboptimal doses were abstracted from notes in the medical chart and from telephone review of previous medication trials with the patient. Results For ACE-i/ARB and beta blockers, rates of prescription in eligible patients were 81% and 94% respectively. However, 71% of patients on an ACE-i/ARB and 81% of patients on a beta blocker were prescribed lower than target doses of these medications. By contrast, utilization of other categories of GDMT was lower in eligible patients, with 59% prescribed MRAs and 16% prescribed an ARNi. As summarized in the Figure, in most cases, the reasons for non-prescription or under-dosing of GDMT by treating clinicians were not apparent on detailed review of the EHR and discussion with the patient. Conclusion Despite widespread utilization of ACEi/ARB and beta blockers in HFrEF, optimization of pharmacologic therapy according to guidelines is inconsistent in clinical practice. The reasons for nonprescription and under-dosing of evidence-based therapies are frequently not apparent from detailed chart review, and only rarely related to documented medication intolerance or contraindications. These data suggest a substantial opportunity for quality improvement.