Use of Target Doses of Guideline Directed Medical Therapy in Heart Failure by Systolic Blood Pressure: Insights from the CHAMP-HF Registry

Abstract

Background Patients with heart failure and reduced ejection fraction (HFrEF) often do not receive target doses of guideline-directed medical therapy (GDMT). Low systolic blood pressure (SBP) may limit GDMT intensification. We examined the prevalence of low SBP as a potential barrier to the use of target doses of GDMT in a contemporary, multi-center cohort of outpatients with HFrEF. Methods In 3095 patients without documented intolerance to ACE-inhibitors (ACEI), angiotensin receptor blockers (ARB), angiotensin receptor-neprilysin inhibitor (ARNI) or beta-blockers (BB) enrolled in the CHAMP-HF registry, we assessed the proportion receiving ≥100% target dose at baseline visit for each drug class before and after stratifying patients by SBP ≥110 or Results Patients were more often male (70.6%), ≥65 years old (59.6%), Caucasian (73.8%) and had SBP≥110 mmHg (78.2%). For each medication class, most patients were receiving ≤50 % of target doses ( Fig 1 a-c). Overall, the proportion of the total population receiving target doses were 10.8% (95% CI: 9.7 - 11.9) for ACEIs/ARBs, 18.7% (95% CI: 17.3 - 20.0) for BB and 2% (1.5 - 2.5) for ARNI ( Fig 1 a). Among those with SBP Fig 1 b). Among those with SBP≥110 (n=2421), target doses were prescribed in 19% (17.4 - 20.6) for BB, 12.1% (10.8 - 13.4) for ACE-I/ARB, and 2% (1.5 - 2.6) for ARNI ( Fig 1 c). Among patients eligible for both BB and ACE-I/ARB/ARNI (n= 1619), only 8.8% (n= 142) were receiving target doses of both ( Fig 1 d). Conclusion In a large, contemporary registry of outpatients with chronic HFrEF eligible for treatment with BB, ACE-I/ARB and ARNI, less than 1 in 5 were receiving target doses, even among those with SBP ≥110 mmHg. SBP alone may not be a major barrier to medication intensification. Other factors should be evaluated to implement novel strategies to improve prescription of GDMT doses.