Guideline-directed Medical Therapy In Patients Research Articles

Validation of a New Scoring Method to Assess the Efficacy of Rapid Initiation and Titration of Combination Pharmacotherapy for Patients Hospitalized with Acute Decompensated Heart Failure with Reduced and Mildly Reduced Ejection Fraction.

Background: Despite the encouragement of early initiation and titration of guideline-directed medical therapy (GDMT) for the treatment of heart failure (HF), most patients do not receive an adequate type and dose of pharmacotherapy in the real world. Objectives: This study aimed to determine the efficacy of titrating composite GDMT in patients with HF with reduced and mildly reduced ejection fraction and to identify patient conditions that may benefit from titration of GDMT. Methods: This was a two-center, retrospective study of consecutive patients hospitalized with acute decompensated heart failure (ADHF). Patients were classified into two groups according to a scoring scale determined by combination and doses of four types of HF agents (ACEis/ARBs/ARNis, BBs, MRAs, and SGLT2is) at discharge. A score of 5 or greater was defined as titrated GDMT, and a score of 4 or less was regarded as sub-optimal medical therapy (MT). Results: A total of 979 ADHF patients were screened. After 553 patients were excluded based on exclusion criteria, 426 patients (90 patients in the titrated GDMT group and 336 patients in the sub-optimal MT group) were enrolled for the analysis. The median follow-up period was 612 (453-798) days. Following statistical adjustment using the propensity score weighting method, the 2-year composite endpoint (composite of cardiac death and HF rehospitalization) rate was significantly lower in the titrated GDMT group, at 19%, compared with the sub-optimal MT group: 31% (score 3-4 points) and 43% (score 0-2 points). Subgroup analysis indicated a marked benefit of titrated GDMT in particular patient subgroups: age < 80 years, BMI 19.0-24.9, eGFR > 20 mL/min/1.73 m2, and serum potassium level ≤ 5.5 mmol/L. Conclusions: Prompt initiation and dose adjustment of multiple HF medications, with careful monitoring of the patient's physiologic and laboratory values, is a prerequisite for improving the prognosis of patients with heart failure.

Guideline-Directed Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction and Incident Cancer

It has been postulated that cancer hampers the delivery of guideline-directed medical therapy (GDMT) for heart failure (HF). However, few data are available in this regard. We performed a retrospective analysis from the HF Outpatient Clinic of the IRCCS Ospedale Policlinico San Martino in Genova, Italy. All HF patients evaluated between 2010 and 2019, with a left ventricular ejection fraction <50% and at least two visits ≥3 months apart with complete information about GDMT were included in the study. We assessed the prescription of GDMT-in particular, beta-blockers (BB), renin-angiotensin system inhibitors (RASi), and mineralocorticoid antagonists (MRA)-at the time of the last HF evaluation and compared it between patients with and without incidental cancer. For those with incidental cancer, we also evaluated modifications of GDMT comparing the HF evaluations before and after cancer diagnosis. Of 464 HF patients, 39 (8%) had incidental cancer. There were no statistical differences in GDMT between patients with and without incidental cancer at last evaluation. In the year following cancer diagnosis, of 33 patients with incidental cancer on BB, none stopped therapy, but two had a down-titration to a dosage <50%; of 27 patients on RASi, two patients stopped therapy and three had a down-titration to a dosage <50%; of 19 patients on MRA, four stopped therapy. Although HF patients with incidental cancer may need to have GDMT down-titrated at the time of cancer diagnosis, this does not appear to significantly hinder the delivery of HF therapies during follow-up.

Initiation and Up-titration of Guideline-directed Medical Therapy for Patients with Heart Failure: Better, Faster, Stronger!

Treatment for heart failure has experienced a major revolution in recent years, and current evidence shows that a combination of four medications (angiotensin receptor-neprilysin inhibitors + β-blockers + mineralocorticoid receptor antagonists + sodium.glucose cotransporter 2 inhibitors) offer the greatest benefit to our patients with significant reductions in cardiovascular mortality, heart failure hospitalisations and all-cause mortality. Unfortunately, despite their proven benefits, the implementation of these therapies is still low. Clinical inertia, and unfounded fear of using these drugs might contribute to this. Recently, evidence from randomised clinical trials has shown that intensive implementation of these therapies in patients with heart failure is safe and effective. In this review, we attempt to tackle some of these misconceptions/fears regarding medical therapy for heart failure and discuss the available evidence showing the best strategies for implementation of these therapies.

Interventions for Optimization of Guideline-Directed Medical Therapy

Implementation of guideline-directed medical therapy (GDMT) in real-world practice remains suboptimal. It is unclear which interventions are most effective at addressing current barriers to GDMT in patients with heart failure with reduced ejection fraction (HFrEF). To perform a systematic review to identify which types of system-level initiatives are most effective at improving GDMT use among patients with HFrEF. PubMed, Embase, Cochrane, CINAHL, and Web of Science databases were queried from January 2010 to November 2023 for randomized clinical trials that implemented a quality improvement intervention with GDMT use as a primary or secondary outcome. References from related review articles were also included for screening. Quality of studies and bias assessment were graded based on the Cochrane Risk of Bias tool and Oxford Centre for Evidence-Based Medicine. Twenty-eight randomized clinical trials were included with an aggregate sample size of 19 840 patients. Studies were broadly categorized as interdisciplinary interventions (n = 15), clinician education (n = 5), electronic health record initiatives (n = 6), or patient education (n = 2). Overall, interdisciplinary titration clinics were associated with significant increases in the proportion of patients on target doses of GDMT with a 10% to 60% and 2% to 53% greater proportion of patients on target doses of β-blockers and renin-angiotensin-aldosterone system inhibitors, respectively, in intervention groups compared with usual care. Other interventions, such as audits, clinician and patient education, or electronic health record alerts, were also associated with some improvements in GDMT utilization, though these findings were inconsistent across studies. This review summarizes interventions aimed at optimization of GDMT in clinical practice. Initiatives that used interdisciplinary teams, largely comprised of nurses and pharmacists, most consistently led to improvements in GDMT. Additional large, randomized studies are necessary to better understand other types of interventions, as well as their long-term efficacy and sustainability.

Guideline-directed medical therapy assessment in heart failure patients undergoing percutaneous mitral valve repair.

Achieving optimized guideline-directed medical therapy (GDMT) is recommended prior to transcatheter mitral valve edge-to-edge repair (M-TEER) for secondary mitral regurgitation (SMR). We aimed to propose and validate an easy-to-use score for assessing the quality of GDMT in patients with heart failure with reduced ejection fraction (HFrEF) undergoing M-TEER. Among the 1641 EuroSMR patients enrolled in the EuroSMR Registry who underwent M-TEER, a total of 1072 patients [median age 74, interquartile range (IQR) 67-79years, 29% female] had complete data on GDMT and a left ventricular ejection fraction≤40% and were included in the current study. We proposed a GDMT score that considers the dosage levels of three medication classes (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists), with a maximum score of 12 points indicating optimal GDMT. The primary outcome was all-cause mortality. The median GDMT score was 4 points (IQR 3-6). All three domains of the scoring system were associated with all-cause mortality (P<0.05 for all). The overall GDMT score was associated with all-cause mortality (hazard ratio 0.90, 95% confidence interval 0.86-0.95 for each 1-point increase in the GDMT score). This association remained significant after adjusting for renal function and co-morbidities. This study demonstrates the utility of a simple GDMT scoring system for assessing the adequacy of GDMT in HFrEF patients with relevant SMR undergoing M-TEER. The GDMT score has potential applications in guiding the design of future clinical trials and aiding clinical decision-making processes.

Guideline-Directed Medical Therapy for Elderly Patients With Acute Myocardial Infarction Who Undergo Percutaneous Coronary Intervention - Insights From a Retrospective Observational Study.

The efficacy of guideline-directed medical therapy (GDMT) in the elderly remains unclear. This study evaluated the impact of GDMT (aspirin or a P2Y12inhibitor, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, β-blocker, and statin) at discharge on long-term mortality in elderly patients with acute myocardial infarction (AMI) who had undergone percutaneous coronary intervention (PCI).Methods and Results: Of 2,547 consecutive patients with AMI undergoing PCI in 2009-2020, we retrospectively analyzed 573 patients aged ≥80 years. The median follow-up period was 1,140 days. GDMT was prescribed to 192 (33.5%) patients at discharge. Compared with patients without GDMT, those with GDMT were younger and had higher rates of ST-segment elevation myocardial infarction and left anterior descending artery culprit lesion, higher peak creatine phosphokinase concentration, and lower left ventricular ejection fraction (LVEF). After adjusting for confounders, GDMT was independently associated with a lower cardiovascular death rate (hazard ratio [HR] 0.35; 95% confidence interval [CI] 0.16-0.81), but not with all-cause mortality (HR 0.77; 95% CI 0.50-1.18). In the subgroup analysis, the favorable impact of GDMT on cardiovascular death was significant in patients aged 80-89 years, with LVEF <50%, or with an estimated glomerular filtration rate ≥30 mL/min/1.73 m2. GDMT in patients with AMI aged ≥80 years undergoing PCI was associated with a lower cardiovascular death rate but not all-cause mortality.

Frailty, Sarcopenia, Cachexia, and Malnutrition in Heart Failure.

With global aging, the number of patients with heart failure has increased markedly. Heart failure is a complex condition intricately associated with aging, organ damage, frailty, and cognitive decline, resulting in a poor prognosis. The relationship among frailty, sarcopenia, cachexia, malnutrition, and heart failure has recently received considerable attention. Although these conditions are distinct, they often exhibit a remarkably close relationship. Overlapping diagnostic criteria have been observed in the recently proposed guidelines and position statements, suggesting that several of these conditions may coexist in patients with heart failure. Therefore, a comprehensive understanding of these conditions is essential, and interventions must not only target these conditions individually, but also provide comprehensive management strategies. This review article provides an overview of the epidemiology, diagnostic methods, overlap, and prognosis of frailty, sarcopenia, cachexia, and malnutrition in patients with heart failure, incorporating insights from the FRAGILE-HF study data. Additionally, based on existing literature, this article discusses the impact of these conditions on the effectiveness of guideline-directed medical therapy for patients with heart failure. While recognizing these conditions early and promptly implementing interventions may be advantageous, further data, particularly from well-powered, large-scale, randomized controlled trials, are necessary to refine personalized treatment strategies for patients with heart failure.

Impact of sodium glucose co-transporter-2 inhibitors on left atrial functions in patients with type-2 diabetes and heart failure with mildly reduced ejection fraction

BackgroundWe aimed to assess the impact of adding sodium glucose co-transporters-2 inhibitors (SGLT-2I) on cardiac remodeling in type 2 diabetic patients with heart failure with mildly reduced ejection fraction (HFmrEF) that had been under-represented in most clinical trials through the analysis of left atrial (LA) phasic functions with 2-D speckle tracking echocardiography (2D- STE MethodsWe enrolled 70 patients with type 2 diabetes (T2DM) and stable HFmrEF (35 patients received one of SGLT-2I either empagliflozin or dapagliflozin). Laboratory assessment and echocardiographic evaluation were carried out at baseline and after 6 months. LA volumes and deformation analysis were conducted using 2D-STE. Three LA strain parameters were obtained (LA reservoir strain, contractile strain, and conduit strain). ResultsAfter 6 months of SGLT-2 I treatment, there was better control of HbA1C and improvement of diastolic functions (E/e′ ratio and LAV-I significantly decreased. P < 0.001*). LVGLS increased, LA functions and all LA strain curve values improved, LA reservoir increased from 17.3 ± 2.0 to 23.8 ± 3.6, LA conduit from 11.0 ± 2.2 to 13.7 ± 2.8 and LA contractile from 6.5 ± 1.4 to 10.5 ± 2.6, P < 0.001* for all. Changes in LA strain values were significantly associated with the changes in LVGLS, LAEF %, E/ e′ ratio, and LAV-I. ConclusionAdding SGLT-2I to existing guideline-directed medical therapy in patients with T2DM and HFmrEF is associated with favorable clinical outcomes and significant improvement of LA volume and functions, with further improvement of LV diastolic and longitudinal functions.

The Impact of Midodrine on Guideline-Directed Medical Therapy in Patients Admitted With Systolic Heart Failure.

Midodrine is occasionally used off-label to treat hypotension associated with advanced heart failure (HF); however, its association with changes in prescription of guideline-directed medical therapy (GDMT) is unknown. We sought to evaluate the effect of midodrine on the GDMT prescription pattern and clinical outcomes of patients with decompensated systolic HF. We retrospectively identified 114 patients admitted to our hospital in 2020 with decompensated systolic HF who were prescribed midodrine on discharge and compared them with 358 patients with decompensated systolic HF who were not prescribed midodrine. At 6 months, the midodrine group had more initiation or up-titration of beta blockers, renin-angiotensin-aldosterone system inhibitors, and sodium-glucose cotransporter-2 inhibitors compared with the nonmidodrine group. Survival at 6 months was similar between the 2 groups, but the midodrine group had more frequent rehospitalization for HF. Our findings suggest that midodrine is associated with improved GDMT in patients with decompensated HF but may be associated with worse prognosis.

Suboptimal guideline-directed medical therapy and prognosis in patients with heart failure and reduced ejection fraction: The SMYRNA Study

Abstract Background Heart failure and reduced ejection fraction (HFrEF) is associated with an increased risk of morbidity and mortality. Despite strong evidence from the randomized-controlled trials and recommendations of guidelines, the use of guideline-directed medical therapy (GDMT) among patients with HFrEF remains suboptimal in a real-life setting. Purpose The Suboptimal guideline-directed Medical therapY and prognosis in patients with heaRt failure and reduced ejectioN frAction (SMYRNA) study aims to determine the prognostic significance of GDMT in patients with HFrEF. Methods The SMYRNA study is a prospective, multicenter, and observational study that included outpatients with HFrEF. The study population enrolled at 41 cardiology centers between January 2019 and June 2019. Patients were divided into 3 groups: those treated with ≤1 class of HF medication, 2 classes of HF medications, and 3 classes of HF medications. The primary outcome was a composite of cardiovascular death or hospitalization for heart failure, analyzed as the time to the first event. Results The study population consisted of 1,062 patients with HFrEF, predominantly men (69.1%), with a median age of 68 (20–96) years. RAS inhibitors, beta-blockers, and MRAs were prescribed in 76.0%, 89.4%, and 55.1%, of the patients at the time of study enrollment, respectively. The proportions of patients receiving target doses of medications were 24.4% for RAS inhibitors, 11.0% for beta-blockers, and 11.1% for MRAs (Figure 1). The median follow-up was 24 months. The rate of primary composite outcome was 40.4% among patients treated with ≤1 class of HF medication, 32.0% among patients treated with 2 classes of HF medications, and 32.8% among patients treated with 3 classes of HF medications. Patients treated with 2 or 3 classes of HF medications had a decreased risk of cardiovascular death or hospitalization for heart failure compared to those patients receiving ≤1 class of HF medication (HR, 0.65; 95% CI, 0.49 to 0.85; P = 0.002, and HR, 0.61; 95% CI, 0.47 to 0.79; P&amp;lt;0.001, respectively, Figure 2). Conclusion The real-life SMYRNA study showed that suboptimal GDMT is strongly associated with an increased risk of cardiovascular death or hospitalization for heart failure in patients with HFrEF.Figure 1Figure 2

Changes in medical therapy after cardiac resynchronization in patients with heart failure: insights from the U.S. Veterans Affairs healthcare system

Abstract Background Patients with heart failure with reduced ejection fraction (HFrEF) are often not treated with comprehensive guideline directed medical therapy (GDMT) due to hemodynamic and renal limitations. Cardiac resynchronization therapy (CRT) improves hemodynamics in patients with HFrEF and ventricular dyssynchrony. Whether CRT facilitates intensification of GDMT in patients with HFrEF has not been well-studied. Purpose To assess pre-procedure GDMT (B-blocker, ACEI [angiotensin converting enzyme inhibitor]/ARB [angiotensin receptor blocker], ARNI [angiotensin receptor neprilysin inhibitor], MRA [mineralocorticoid receptor antagonist], SGLT2i [sodium-glucose cotransporter-2 inhibitor]) utilization in HFrEF patients who received CRT and to compare changes in GDMT in patients who received CRT with patients who received implantable cardioverter-defibrillator (ICD). Methods Veterans with left ventricular ejection fraction (LVEF) 35% who received CRT or ICD from Feb 22, 2000 – Jul 28, 2022 were identified. Patients with end-stage renal disease were excluded. Changes in GDMT 12-months following device implant were characterized and compared between CRT and ICD recipients. Mixed effects logistic regression models were generated to evaluate associations between receipt of CRT and the composite of therapy initiation, dose increase, or target dose achievement compared with ICD. Models were adjusted for clinical characteristics and pre-implant GDMT utilization. Similar models were developed to evaluate the adjusted associations between CRT and changes in estimated glomerular filtration rate (eGFR) and blood pressure (BP) compared with ICD. Results A total of 2,082 CRT recipients and 7,263 ICD recipients were identified. Pre-procedure heart rate, BP, serum potassium, and eGFR were within normal ranges and similar between groups. Prior to device implant, ACEI/ARB/ARNI were most frequently prescribed (91%), followed by -blockers (88%), MRA (46%), and SGLT2i (33% in post-SGLT2i era). Pre-procedure GDMT was similar between CRT and ICD recipients. At 12 months follow-up, CRT was independently associated with increased odds of therapy initiation, dose increase, or target dose achievement for ACEI/ARB/ARNI, ARNI, B-blockers, and MRA (Figure 1). ICD was associated with a decline in eGFR while CRT was associated with an increase in eGFR (mean [standard deviation]: -0.95 [0.17] vs. +0.6 [0.29]; p&amp;lt;0.01), while no differences were observed in BP or LVEF at 12 months. Conclusions In a large, contemporary cohort of patients with HFrEF, most patients were not prescribed MRA or SGLT2i prior to receiving CRT or ICD despite no apparent renal or blood pressure-related contraindications. CRT is associated with increased odds of the composite of initiation, dose increase, or target dose achievement for ACEI/ARB/ARNI, ARNI, B-blockers, and MRA compared with ICD. GDMT intensification may be mediated by beneficial changes in kidney function in CRT recipients.Figure 1

Analysis of Physician Compliance with Guideline-Directed Medical Therapy for Patients with Heart Failure with Reduced Ejection Fraction: A Real-World Study

Analysis of Physician Compliance with Guideline-Directed Medical Therapy for Patients with Heart Failure with Reduced Ejection Fraction: A Real-World Study

Underutilisation of Guideline-Directed Medical Therapy in Patients With HFrEF and Ventricular Tachycardia Requiring Radiofrequency Ablation

Underutilisation of Guideline-Directed Medical Therapy in Patients With HFrEF and Ventricular Tachycardia Requiring Radiofrequency Ablation

Use of midodrine in heart failure: a review.

Heart failure is a global health concern, affecting millions of individuals worldwide. Midodrine, an alpha-1 receptor agonist, might be a potential treatment option for patients with heart failure and concurrent hypotension. This review provides a comprehensive summary of the existing literature on the use of midodrine in heart failure patients, focusing on its pharmacology, epidemiology, and public health impact. Guideline-directed medical therapy (GDMT) is essential in heart failure management, but hypotension may limit its initiation or up-titration. Studies have shown that midodrine can improve blood pressure, reduce the need for vasopressor support, and enable the prescription of GDMT in patients who are intolerant to it due to hypotension. However, there are concerns over increased all-cause mortality in some studies, small sample sizes, and nonrandomized study designs in others. Further research, including large-scale randomized controlled trials and long-term follow-up studies, is needed to better understand the risks and benefits of midodrine use in heart failure patients, particularly in relation to GDMT. Clinicians should consider the potential advantages of midodrine against the limited evidence and potential risks before incorporating it into their clinical practice for heart failure treatment.

Guideline-Directed Medical Therapy and Long-Term Mortality and Amputation Outcomes in Patients Undergoing Peripheral Vascular Interventions

BackgroundLack of guideline-directed medical therapy (GDMT) in patients undergoing peripheral vascular interventions (PVIs) may increase mortality and amputation risk. ObjectivesThe authors sought to study the association between GDMT and mortality/amputation and to examine GDMT variability among providers and health systems. MethodsWe performed an observational study using patients in the Vascular Quality Initiative registry undergoing PVI between 2017 and 2018. Two-year all-cause mortality and major amputation data were derived from Medicare claims data. Compliance with GDMT was defined as receiving a statin, antiplatelet therapy, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker if hypertensive. Propensity 1:1 matching was applied for GDMT vs no GDMT and survival analyses were performed to compare outcomes between groups. ResultsOf 15,891 patients undergoing PVIs, 48.8% received GDMT and 6,120 patients in each group were matched. Median follow-up was 9.6 (IQR: 4.5-16.2) months for mortality and 8.4 (IQR: 3.5-15.4) for amputation. Mean age was 72.0 ± 9.9 years. Mortality risk was higher among patients who did not receive GDMT versus those on GDMT (31.2% vs 24.5%; HR: 1.37, 95% CI: 1.25-1.50; P < 0.001), as well as, risk of amputation (16.0% vs 13.2%; HR: 1.20; 95% CI: 1.08-1.35; P < 0.001). GDMT rates across sites and providers ranging from 0% to 100%, with lower performance translating into higher risk. ConclusionsAlmost one-half of the patients receiving PVI in this national quality registry were not on GDMT, and this was associated with increased risk of mortality and major amputation. Quality improvement efforts in vascular care should focus on GDMT in patients undergoing PVI.

Defining the gap in heart failure treatment in patients with cardiac implantable electronic devices.

The use of guideline-directed medical therapy (GDMT) is poorly described in patients with heart failure and reduced ejection fraction (HFrEF) with cardiac resynchronization therapy (CRT) and/or implantable cardioverter defibrillators (ICDs). To define the eligibility, uptake, dose, contraindications, and barriers to uptake of contemporary medical therapy in this population. Retrospective analysis of consecutive adults with ICD and/or CRT attending two Canadian tertiary centre device clinics between 1 March and 31 May 2021. From 1005 device clinic consultations, 227 (22.6%) patients with HFrEF and CRT and/or ICD were included. GDMT eligibility was high: beta-blockers (99.6%), mineralocorticoid receptor antagonists (MRA) (89.0%), angiotensin receptor-neprilysin inhibitors (ARNI) (84.6%), and sodium-glucose cotransporter-2 inhibitors (SGLT2I) (87.7%). Contraindications were rare: beta-blockers (0.4%), MRA (11.0%), ARNI (15.4%), and SGLT2I (12.3%). Uptake of GDMT was high for beta-blockers (97.4%) but low for other medications: MRA (63.0%), ARNI (46.7%), SGLT2I (22.9%). Except for SGLT2I (84.6%) and beta-blockers (57.9%), less than one-half of patients were prescribed target-doses of MRA (10.5%), and ARNI (47.7%). Of the visits, GDMT was already optimal in 16%, electrophysiologists acted in 33% (21% prescribed, 7% ordered investigations, 5% referred to heart function services), and in the remaining visits, optimization was either deferred to another cardiologist (20%) or no plan was mentioned (25%), besides other reasons (4%). Despite broad eligibility for GDMT in patients with HFrEF and ICD/CRT, significant gaps in prescription and titration exist. Our results highlight the need to embed quality assurance initiatives in cardiac device clinics to improve HFrEF care.

Low blood pressure and guideline-directed medical therapy in patients with heart failure with reduced ejection fraction

BackgroundPatients with heart failure (HF) presenting with low blood pressure (BP) have been underrepresented in large-scale clinical trials. We investigated the characteristics and implementation of conventional guideline-directed medical therapy (GDMT; renin-angiotensin system inhibitors and β-blockers) in patients with low BP hospitalized for HF with systolic dysfunction. MethodsConventional GDMT was evaluated by discharge BP among 2043 consecutive patients with HF and left ventricular ejection fraction (LVEF) < 50% in the WET-HF registry. Among the 708 (34.7%) patients with lower discharge BP (≤ 100 mmHg; the lower tertiles), exploratory subgroups included patients with previous HF hospitalization, inotrope use, New York Heart Association (NYHA) III–IV class, and lower estimated glomerular filtration rate (eGFR) and LVEF (lower than median value). We evaluated the risk-adjusted association between GDMT implementation and 2-year adverse events (all-cause mortality or HF rehospitalization). ResultsAmong the 2043 patients (age 74 [63–82] years), the median systolic BP was 108 (98–120) mmHg. Among patients with lower BP, GDMT prescription rate was 62.7%, and GDMT use was associated with decreased adverse events (HR:0.74, 95%CI:0.58–0.94). GDMT prescription rates were lower among higher-NYHA class and lower-eGFR subgroups compared with their reference subgroups, and directionally similar outcomes were noted in all subgroups (favoring GDMT use); however, this association was somewhat attenuated in the lower-eGFR group (HR:0.87, 95%CI:0.64–1.17). ConclusionsConventional GDMT use was associated with decreased adverse outcomes in most patients with HF compounded by systolic dysfunction and low BP, albeit caution is warranted in patients with renal dysfunction.

Prognostic impact of guideline-directed medical therapy in patients with heart failure on regular hemodialysis

BackgroundRenin-angiotensin system inhibitor (RASi) and β-blocker provide prognostic benefits as guideline-directed medical therapy (GDMT) in patients with heart failure and reduced ejection fraction (HFrEF). However, there is limited data for the favorable effects in such patients receiving regular hemodialysis. We aimed to evaluate the prognostic impact of RASi and β-blocker in patients with HFrEF who receive regular hemodialysis. MethodsIn this retrospective, single-center, observational study, from 2110 consecutive patients hospitalized for HF and who survived to discharge, 97 with HFrEF who received regular hemodialysis were included for analysis. They were classified into three groups according to prescribed medication at discharge following index hospitalization: both RASi and β-blocker (Dual-GDMT group: n = 55), either RASi or β-blocker (Mono-GDMT group: n = 34), and neither RASi nor β-blocker (No-GDMT group: n = 8). The primary endpoint was a composite of all-cause death and rehospitalization for heart failure. ResultsThe mean age was 66 years and 79% of the patients were men. During the median follow-up of 501 days, the primary endpoint occurred in 43 patients (44%). Kaplan-Meier analysis revealed that the Dual-GDMT group had the lowest rates of the primary endpoint (log-rank test for trend: p < 0.001). Even after adjustment for diverse covariates (multivariate Cox regression), the Dual-GDMT (hazard ratio [HR]: 0.04, 95% confidence interval (CI): 0.005–0.32) and Mono-GDMT (HR: 0.08, 95% CI: 0.01–0.50) groups had better prognoses than the No-GDMT group. ConclusionsThe prescription of RASi and/or β-blocker was associated with a lower adverse-event rate after discharge in patients with HFrEF who were on regular hemodialysis.

Leveraging clinical decision support tools to improve guideline-directed medical therapy in patients with atherosclerotic cardiovascular disease at hospital discharge.

BackgroundGuidelines recommend moderate to high-intensity statins and antithrombotic agents in patients with atherosclerotic cardiovascular disease (ASCVD). However, guideline-directed medical therapy (GDMT) remains suboptimal.MethodsIn this quality initiative, best practice alerts (BPA) in the electronic health record (EHR) were utilized to alert providers to prescribe to GDMT upon hospital discharge in ASCVD patients. Rates of GDMT were compared for 5 months pre- and post-BPA implementation. Multivariable regression was used to identify predictors of GDMT.ResultsIn 5985 pre- and 5568 post-BPA patients, the average age was 69.1 ± 12.8 years and 58.5% were male. There was a 4.0% increase in statin use from 67.3% to 71.3% and a 3.1% increase in antithrombotic use from 75.3% to 78.4% in the post-BPA cohort.ConclusionsThis simple EHR-based initiative was associated with a modest increase in ASCVD patients being discharged on GDMT. Leveraging clinical decision support tools provides an opportunity to influence provider behavior and improve care for ASCVD patients, and warrants further investigation.

It's not all about ISCHEMIA: the case for coronary artery bypass grafting in stable coronary artery disease.

The recent American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions Guidelines for Coronary Artery Revascularization have raised concerns on the survival benefits of coronary artery bypass grafting (CABG) over guideline-directed medical therapy (GDMT) in stable coronary artery disease (CAD) and appropriate conduit selection for CABG. This review summarizes the evidence supporting CABG for stable CAD and use of the radial artery as a conduit for CABG. CABG has consistently demonstrated a survival benefit over GDMT for patients with stable multivessel CAD. These benefits were more pronounced in patients with diabetes and/or anatomically complex coronary artery disease. The recently published International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial was not designed to and did not include an appropriate patient population to compare revascularization with CABG to GDMT. These results should thus be viewed in the context of previously published studies. Furthermore, increasing evidence suggests that use of a radial artery in CABG is associated with reduced myocardial infarction and repeat revascularization. This should be considered when selecting the appropriate conduits based on underlying patient factors. Readers should be cautious when applying these guidelines broadly. Appropriate consideration of patient and anatomic factors, and in consultation with a multidisciplinary heart team, is important to achieve the best outcomes for patients.