Utilization of Mineralocorticoid Receptor Antagonists in an Advanced Heart Failure and Transplant Program in The Middle East

Abstract

Background Heart failure with reduced ejection fraction (HFrEF) outcomes are influenced by optimal guideline-directed medical therapy (GDMT). This includes target doses of mineralocorticoid receptor antagonists (MRA). The underuse and under-dosing of this particular class of GDMT have been reported before. Recent studies have also demonstrated that some of the perceived concerns, such as lowering systolic blood pressure (SBP) that might preclude utilization of MRA in HFrEF, may only be theoretical. This study aims to explore MRA utilization and associated factors in an advanced heart failure program at a quaternary care center in the Middle East- Gulf Region. Methods We conducted a retrospective electronic chart review of all HFrEF patients presenting to the outpatient clinic in our program and followed them for one year. The group of patients who achieved MRA target dose at the one-year visit were compared to those who did not reach this goal. Descriptive analysis was performed for patient characteristics and a logistic regression was specified to examine predictors of reaching MRA target dose. Results A total of 123 HFrEF patients were included in this study for a mean follow-up period of 363.8±31 days. Table 1 shows patient characteristics and GDMT use at baseline and at 1-year follow-up. While more patients were on target doses of beta blockers and ACE/ARB/ARNI at follow-up when compared to baseline (p-value <0.05), this finding did not extend to MRA therapy. Only baseline renal function and serum potassium but not SBP were associated with reaching the target dose of MRA at the 1-year follow-up (Table 2). A 14.9 % decrease in the odds of receiving a target dose of MRA was observed for each 0.1 mmol/L increase in baseline potassium. An eGFR of ≥60 mL/minute/per 1.73 m2 correlated with a 207% increase in odds of being on target dose MRA when compared to lower eGFR. Conclusion In our advanced heart failure and transplant program, renal function and serum potassium but not SBP are associated with the titration of MRA therapy. While such programs might have a better understanding of the correct utilization and associated outcomes with this class of medication, there still needs to be more adoption of this important therapy. Heart failure with reduced ejection fraction (HFrEF) outcomes are influenced by optimal guideline-directed medical therapy (GDMT). This includes target doses of mineralocorticoid receptor antagonists (MRA). The underuse and under-dosing of this particular class of GDMT have been reported before. Recent studies have also demonstrated that some of the perceived concerns, such as lowering systolic blood pressure (SBP) that might preclude utilization of MRA in HFrEF, may only be theoretical. This study aims to explore MRA utilization and associated factors in an advanced heart failure program at a quaternary care center in the Middle East- Gulf Region. We conducted a retrospective electronic chart review of all HFrEF patients presenting to the outpatient clinic in our program and followed them for one year. The group of patients who achieved MRA target dose at the one-year visit were compared to those who did not reach this goal. Descriptive analysis was performed for patient characteristics and a logistic regression was specified to examine predictors of reaching MRA target dose. A total of 123 HFrEF patients were included in this study for a mean follow-up period of 363.8±31 days. Table 1 shows patient characteristics and GDMT use at baseline and at 1-year follow-up. While more patients were on target doses of beta blockers and ACE/ARB/ARNI at follow-up when compared to baseline (p-value <0.05), this finding did not extend to MRA therapy. Only baseline renal function and serum potassium but not SBP were associated with reaching the target dose of MRA at the 1-year follow-up (Table 2). A 14.9 % decrease in the odds of receiving a target dose of MRA was observed for each 0.1 mmol/L increase in baseline potassium. An eGFR of ≥60 mL/minute/per 1.73 m2 correlated with a 207% increase in odds of being on target dose MRA when compared to lower eGFR. In our advanced heart failure and transplant program, renal function and serum potassium but not SBP are associated with the titration of MRA therapy. While such programs might have a better understanding of the correct utilization and associated outcomes with this class of medication, there still needs to be more adoption of this important therapy.