Guideline-directed Medical Therapy Prescription Research Articles

Impact of discharge checklist on guidelinedirected medical therapy and mid-term prognosis in heart failure.

Despite the proven benefit of the guideline-directed medical therapy (GDMT), it remains underutilized in patients hospitalized with acute heart failure (HF). We aimed to evaluate the impact of the discharge checklist on GDMT installation and the prognosis of HF patients. This study was a single-center, observational study that included all patients admitted for HF from March 2021 to February 2023. The data were retrieved from electronic medical records and discharge checklists. A comparison was conducted between the checklist group and the non-checklist group. The primary endpoint was a composite of all-cause mortality or readmission for HF within 6 months. The checklist was completed for 537 patients (checklist group) and not for 187 patients (non-checklist group). The proportion of patients to whom two or more components of GDMT were prescribed was significantly higher in the checklist group than in the non-checklist group (59.6% vs 42.2%, p < 0.001). The checklist group exhibited a significantly lower primary outcome compared to the non-checklist group (27.4% vs. 36.4%, HR 0.73, 95% CI 0.55-0.98, p = 0.036). The effect of the checklist was more prominent in HF with reduced ejection fraction (HR 0.51, 95% CI 0.34-0.77, p = 0.001) than in HF with mildly-reduced and preserved ejection fraction (HR 0.91, 95% CI 0.58-1.42, p = 0.676) (p for interaction = 0.06). The implementation of the discharge checklist was associated with an improvement in GDMT prescription and an improved prognosis in patients with HF with reduced ejection fraction.

Efficacy, Safety and Mechanistic Impact of a Heart Failure Guideline-Directed Medical Therapy Clinic

BackgroundAlthough clinical evidence supports rapid institution of guideline-directed medical therapy (GDMT) for heart failure (HF), in actual practice, there remain large gaps in adherence to guideline recommendations. Recent data support safety and efficacy of rapid GDMT implementation; however, rapid GDMT deployment within a general cardiology environment remains unexplored. ObjectivesThe purpose of this study was to evaluate the efficacy and safety of a GDMT clinic within a general cardiology practice relative to usual care, the impact on prescription of GDMT, HF symptoms, N-terminal pro–B-type natriuretic peptide concentrations and echocardiographic parameters of remodeling. MethodsIndividuals with HF with an abnormal ejection fraction (<50%) referred to the GDMT clinic underwent rapid GDMT titration with close monitoring of clinical data. Rates of GDMT prescription were compared with a matched reference group. Patients underwent echocardiography at baseline and after GDMT clinic completion. ResultsA total of 114 persons were treated in GDMT clinic. The mean age was 67.6 ± 14.6 years, and 32 (28%) were women. Among those referred, 100 (87.7%) had no contraindications for 4-drug GDMT. From baseline to clinic completion (median 15.8 weeks [Q1-Q3: 10.7-23.0 weeks]), patients without medication contraindications experienced significant increases in 4-drug GDMT use (from 21% to 88%; P < 0.001); of 4-drug GDMT recipients, 92% received angiotensin receptor neprilysin inhibitor. GDMT clinic participants achieved higher medication doses than those in usual care, with greater achievement of ≥50% target dose of angiotensin receptor neprilysin inhibitor (52% vs 8%), beta-blocker (78% vs 6.2%), mineralocorticoid receptor antagonist (98% vs 15.6%), and sodium-glucose cotransporter 2 inhibitors (92% vs 6.2%). Target doses of all 4 drugs were reached in nearly 1 in 4 participants. HF symptoms improved (94% to 75% NYHA functional class II/III; P < 0.001) and N-terminal pro–B-type natriuretic peptide concentration decreased (median 587 to 534 ng/L; P = 0.03) despite loop diuretic reduction. Additionally, we observed an absolute 6% LVEF increase (from 37% [Q1-Q3: 31%-41%] to 43% [Q1-Q3: 38%-53%]; P < 0.001) and substantial decrease in moderate or severe mitral regurgitation. GDMT titration was well-tolerated. ConclusionsRapid GDMT implementation via an outpatient GDMT clinic was effective, safe, and associated with improvement in key clinical parameters. The more widespread role of GDMT clinics to improve HF care warrants further study.

Prescription Patterns in Management of Heart Failure and Its Association With Readmissions: A Retrospective Analysis

BackgroundThe American Heart Association/American College of Cardiology/Heart Failure Society of America recently added sodium-glucose cotransporter-2 inhibitors in addition to renin–angiotensin–aldosterone system inhibitors, beta-blockers, and mineralocorticoid receptor antagonists to form the 4 pillars of guideline-directed medical therapy (GDMT) for the management of heart failure with reduced ejection fraction (HFrEF). Despite strong evidence suggesting improved outcomes with inpatient initiation of GDMT at target doses, significant lag has been noted in prescription practices. We sought to study GDMT prescription rates in patients with HFrEF at the time of hospital discharge and evaluate its association with various patient characteristics and all-cause readmission rates. Methods and ResultsWe used a modified version of Heart Failure Collaboratory (HFC) score to characterize patients into 2 groups (those with an HFC score of <3 and an HFC score of ≥3) and to examine various socioeconomic and biomedical factors affecting GDMT prescription practices. Out of the eligible patients, the prescription rates for beta-blockers was 77.9%, renin–angiotensin–aldosterone system inhibitor was 70.3%, and mineralocorticoid receptor antagonists was 41%. Furthermore, prescription rates for sacubitril/valsartan was 27.7% and sodium-glucose cotransporter-2 inhibitors was 17%. Only 1% of patients had an HFC score of 9 (drugs from all 4 classes at target doses). Patients of black ethnicity, those admitted on teaching service and those with HFrEF as the primary cause of admission were more likely to have an HFC of ≥3 at discharge. An HFC of ≥3 was associated with lower rates of 1-month all-cause readmissions. ConclusionsConsistent with the prior research, our data show significant gaps in prescription of GDMT in HFrEF. Further implementation research should be done to improve GDMT prescription during inpatient stay.

Guideline-directed medical therapy prescribing patterns and in-hospital outcomes among heart failure patients during COVID-19

Study objectiveThe association of prior to admission guideline-directed medical therapy (GDMT) use in patients hospitalized with Heart Failure with Reduced Ejection Fraction (HFrEF, ejection fraction ≤40 %) and Coronavirus Disease 2019 (COVID-19) with in-hospital outcomes has not been well studied. Design/setting/participants/interventions/outcome measuresUsing the American Heart Association's Get With The Guidelines Heart Failure Registry, we identified HFrEF patients presenting with acute decompensated heart failure (ADHF) and compared rates of GDMT prescription between those presenting prior to and during the pandemic. In a subgroup of patients with a concomitant COVID-19 diagnosis, we evaluated the association of prior to admission GDMT use with in-hospital mortality and severe COVID-19. Results23,899 patients were admitted with HFrEF during the pandemic (2/16/20–3/24/21) and 26,459 patients were admitted in the year prior (2/16/19–2/15/20). In this overall cohort, prior to admission ACEI/ARB/ARNI (45.6 % vs 48.1 %, p < 0.0001) and BB (56.9 % vs 62.4 %, p < 0.0001) use was lower among admitted HFrEF patients during the pandemic when compared to the year prior. Rates of ACEI/ARB/ARNI, MRA, and triple therapy (ACE/ARB/ARNI + BB + MRA) prescription at discharge were higher during the pandemic compared to the year prior. Among a subgroup of those with HFrEF and COVID-19 (n = 333), prior to admission GDMT use was not associated with in-hospital mortality or severe COVID-19. ConclusionWe found no association between prior to admission GDMT use and in-hospital mortality or severe COVID-19 among HFrEF patients admitted with ADHF and COVID-19. GDMT prescription at discharge for HFrEF patients overall has remained either similar or improved during the pandemic.

Impact of Dedicated Cardiologist Input on the Rate of Prescription of Guideline-Directed Medical Therapy after Coronary Artery Bypass Graft Surgery—A Retrospective Cohort Study

Impact of Dedicated Cardiologist Input on the Rate of Prescription of Guideline-Directed Medical Therapy after Coronary Artery Bypass Graft Surgery—A Retrospective Cohort Study

Association of multimorbidity with guideline-directed medical therapy intensification in heart failure: Findings from the EPIC-HF trial

A potential contributor to the suboptimal rates of guideline directed medical therapy (GDMT) prescribing for heart failure with reduced ejection fraction (HFrEF) is the burden of multimorbidity in patients with HFrEF. We examined the effect of multimorbidity on GDMT prescription in the EPIC-HF trial, finding that multimorbidity was associated with decreased likelihood of GDMT intensification. Further study is needed to guide treatment in high-risk, multimorbid patients with HFrEF.

Medication and Outcome in Older Heart Failure Patients: Results from a Prospective Cohort Study.

Purpose: Acute heart failure (AHF) is associated with high morbidity and mortality, and the prognosis is particularly poor in older patients. Although the application of guideline-directed medical therapy (GDMT) has shown a positive impact on prognosis, the effects are less clear in older age groups. The aim of this study was to analyze real-world data regarding GDMT and outcomes in older HF patients. Methods: This is a prospective cohort study from a secondary care hospital in central Switzerland. A total of 97 consecutive patients aged ≥60 years were enrolled between January 2019 and 2022. The main outcome parameters were prescribed GDMT at discharge, and in case of rehospitalization, GDMT at readmission, and survival in terms of all-cause mortality and HF-related hospitalizations during a 3-year follow-up period. Results: Follow-up data were available for 93/97 patients. The mean age was 77.8 ± 9.8 years, 46% being female. The mean left ventricular ejection fraction (LVEF) was 35.3 ± 13.9%, with a mean BNP level of 2204.3 ± 239 ng/L. Upon discharge, 86% received beta-blockers and 76.3% received renin-angiotensin system (RAS) inhibitors. At rehospitalization for AHF, beta-blockers use was significantly lower and decreased to 52.8% (p = 0.003), whereas RAS inhibitor use increased slightly to 88.9% (p = 0.07), and SGLT-2 inhibitors showed a significant increase from 5.4% vs. 47.2% (p = 0.04). GDMT prescription was not dependent on LVEF. Overall, 73.1% of patients received two-stage or three-stage GDMT at discharge, whereas this percentage decreased to 61% at rehospitalization (p = 0.01). Kaplan-Meier analysis for the combined outcome rehospitalization and death stratified by LV function showed significant differences between LVEF groups (aHR: 0.6 [95% CI: 0.44 to 0.8]; p = 0.0023). Conclusions: Our results indicate that first, the majority of older AHF patients from a secondary care hospital in Switzerland were not on optimal GDMT at discharge and even fewer at readmission, and second, that prognosis of the population is still poor, with almost half of the patients having been rehospitalized or died during a 3-year follow-up period under real-world conditions, without significant difference between women and men. Our findings underline the need for further improvements in the medical treatment of AHF, in particular in older patients, to improve prognosis and to reduce the burden of disease.

Recovery of left ventricular systolic function in peripartum cardiomyopathy: an observational study from rural Tanzania

BackgroundThe aim of this study was to evaluate the recovery rate of the left ventricular systolic function of women diagnosed with peripartum cardiomyopathy receiving specialized care in rural Tanzania.MethodsIn this observational study, women diagnosed with peripartum cardiomyopathy at a referral center in rural Tanzania between December 2015 and September 2021 were included. Women diagnosed between February and September 2021 were followed prospectively, those diagnosed between December 2015 and January 2021 were tracked back for a follow-up echocardiography. All participants received a clinical examination, a comprehensive echocardiogram, and a prescription of guideline-directed medical therapy. The primary outcome was recovery of the left ventricular systolic function (left ventricular ejection fraction > 50%).ResultsMedian age of the 110 participants was 28.5 years (range 17–45). At enrolment, 49 (45%) participants were already on cardiac medication, 50 (45%) had severe eccentric hypertrophy of the left ventricle, and the median left ventricular ejection fraction was 30% (range 15–46). After a median follow-up of 8.98 months (IQR 5.72–29.37), 61 (55%) participants were still on cardiac medication. Full recovery of the left ventricular systolic function was diagnosed in 76 (69%, 95% CI 59.6–77.6%) participants. In the multivariate analysis, a higher left ventricular ejection fraction at baseline was positively associated with full recovery (each 5% increase; OR 1.7, 95% CI 1.10–2.62, p = 0.012), while higher age was inversely associated (each 10 years increase; OR 0.40, 95% CI 0.19–0.82, p = 0.012).ConclusionLeft ventricular systolic function recovered completely in 69% of study participants with peripartum cardiomyopathy from rural Tanzania under specialized care.

Impact of a Quality Improvement Initiative on Medical Management of Veterans With Peripheral Artery Disease

Guideline-directed medical therapy (GDMT) for peripheral artery disease (PAD) remains severely underused. Prevention of Amputation in Veterans Everywhere (PAVE) is a screening program designed to prevent or delay major lower extremity amputation. This study aimed to determine whether diagnosis of PAD through the PAVE program improves the prescription of GDMT in veterans with asymptomatic PAD. Patients enrolled into the PAVE program from our institution from 2020 to 2021 were included. Patients with an abnormal ankle-brachial index (ABI), defined as ABI <0.9 or >1.2, were selected for further analysis. Primary outcome was adherence to GDMT, following class I and class IIa recommendations. Secondary outcomes included changes in low-density lipoprotein (LDL), blood pressure, and hemoglobin A1c (HbA1c). A total of 6,313 patients were enrolled into the PAVE program between 2020 and 2021. Of these, 211 had abnormal ABI and were included in our analysis. With enrollment into PAVE, there was significant increase in the prescription of aspirin (74.4% vs 64.9%, p = 0.044) and statins (91.5% vs 82%, p = 0.006). The overall adherence to GDMT significantly increased (56.9% vs 38.9%, p <0.001). The number of patients needed to enroll in PAVE to improve GDMT adherence is 5.6 (95% confidence interval 3.6 to 12.3). Patients enrolled into PAVE program saw significant decreases in HbA1c, with mean decrease of 0.3 (p = 0.012) and a decrease in LDL, with a mean decrease of 6.2 (p = 0.01). In conclusion, enrollment into an amputation prevention program secondarily increased adherence to GDMT, driven by increases in the prescription of statins and aspirin, with resulting decreases in HbA1c and LDL.

Abstract P156: Insurance Impact on Guideline-Directed Medical Therapy Prescription in HIV Heart Failure Patients: Past vs. Present Data From New York City's Largest Public Healthcare System

Introduction: Guideline-Directed Medical Therapy (GDMT), comprising renin-angiotensin system inhibitors, evidence-based β-blockers, mineralocorticoid inhibitors, and sodium glucose cotransporter 2 inhibitors, significantly enhances patient survival in heart failure cases. However, the impact of public insurance, private coverage, and being uninsured on GDMT for HIV heart failure patients is understudied. This research compares GDMT prescriptions across various insurance types over time. Method: This study analyzed data from the New York City Health + Hospitals HIV Heart Failure (NYC 4H) retrospective cohort, comprising records from eleven major NYC Health + Hospitals. Patients were recruited from hospital visits, both inpatient and clinic, spanning from July 2017 to June 2022. Follow-up records were reviewed between July 2022 and August 2023. Insurance types were determined based on primary insurance coverage in the medical charts. Guideline-directed medical therapy (GDMT) was reviewed at baseline and follow-up encounter. Insurance coverage and GDMT prescriptions were compared using chi-square tests. Multivariable logistic regression models, adjusted for age, sex, race, and co-morbidities, were employed to observe the association between insurance and GDMT prescriptions. Result: A total of 726 HIV heart failure patients participated in the study, including 263 with Medicare, 334 with Medicaid, 96 with private insurance, and 33 without insurance. Significant difference in GDMT prescriptions were evident at baseline, with &gt;1 and &gt;2 GDMT prescriptions being higher among uninsured (69.7% and 36.4%) and Medicare (66.2% and 37.6%) patients compared to Medicaid (54.8% and 29.9%) and private insurance patients (55.2% and 20.8%) (P&lt;0.05). Private insurance holders exhibited a 49% lower likelihood of receiving &gt;2 GDMT prescriptions than Medicare beneficiaries after adjusting for age, sex, race, and co-morbidities (adjusted odds ratio [aOR] 0.51, 95% confidence interval [CI] [0.28, 0.93], p&lt;0.05). Over the four-year follow-up, prescription rates for GDMT medications notably increased. However, disparities persisted in &gt;1 and &gt;2 GDMT prescriptions across insurance types, including 90.9% and 51.5% for uninsured, 76% and 48.3% for Medicare, 72.8% and 45.2% for Medicaid, and the lowest rates of 66.7% and 35.4% for private insurance patients, respectively (P&lt;0.05). After adjusting for covariates, no statistically significant differences in GDMT prescriptions were found across insurance type. Conclusion: GDMT prescriptions significantly improved over the follow-up period within HIV heart failure population. Although the differences diminished slightly, private insurance beneficiaries consistently exhibited the lowest GDMT prescription rates at both baseline and follow-up, in comparison to Medicare, Medicaid, and the uninsured population.

Emulated Trial for Discharge Prescription of Guideline-Directed Medical Therapy and 15-Year Survival After Coronary Artery Bypass Graft Surgery

ObjectivesTo explore admission and discharge prescription rates of guideline-directed medical therapy (GDMT), defined as aggregate antiplatelet agents, statins, and β-blockers, after coronary artery bypass graft (CABG) surgery and to reveal its association with long-term survival. Patients and MethodsThis is a prospective cohort study–based emulated trial of patients undergoing elective or semi-elective isolated CABG surgery in 7 cardiothoracic units in Israel from January 1, 2004, to December 31, 2007, and followed up until December 31, 2020, for all-cause mortality. ResultsOnly 59.2% of 968 patients (n=573) were discharged on GDMT after CABG surgery. Admission GDMT use conferred a 7 times greater likelihood of discharge GDMT prescription (odds ratio, 7.07; 95% CI, 5.04 to 9.91; P<.001), with no sex differences observed. After applying inverse probability of treatment weighting, baseline characteristics were well balanced between groups. During a median follow-up of 13.7 years, a Cox regression model with propensity score–adjusted inverse probability of treatment weighting revealed lower mortality in patients with discharge GDMT prescription who underwent CABG surgery than in their counterparts (hazard ratio, 0.75; 95% CI, 0.60 to 0.93; P=.008). ConclusionThe use of aggregate GDMT before surgery conferred a greater likelihood of GDMT prescription upon discharge, which, in turn, is associated with better long-term survival. Educational efforts of pertinent medical professionals are needed to minimize preventive treatment gaps. Trial Registrationclinicaltrials.gov Identifier: NCT00356863

Variability in guideline-directed medical therapy across sites and operators and long-term mortality and amputation outcomes risk in patients undergoing peripheral vascular interventions

The use of guideline-directed medical therapy (GDMT) in patients undergoing peripheral vascular interventions (PVIs) decreases the risk of death and amputation and may decrease hospital readmissions. The variability of GDMT prescription across sites and operators and the proportionality of risk is not well understood. We aimed to study the association between variability of GDMT prescription at the site and operator level and outcomes (including 90-day readmissions and 24-month all-cause mortality and major amputation). We examined GDMT discharge rates in PVIs performed between 2017 and 2018 using Medicare-linked Vascular Quality Initiative registry. GDMT included a statin, antiplatelet therapy, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE-i/ARB) if hypertensive. Quartiles (Q1-4) of GDMT rates were documented by operators and sites and variability was quantified using median odds ratios (MOR) and intraclass correlation (ICC). The association between lower GDMT rates (per 10%) by sites and operators with 90-day readmission were calculated using logistic regression, and with 24-month mortality and major amputation using parametric survival model. Models were adjusted for patient-level factors and included sites and operators nested within sites as 2 random effects. GDMT rates for 17,147 patients across 223 sites and 1,263 operators ranged from 0% to 38% (Q1, MOR 1.43, 95%CI 1.39-1.47, P ≤ .001) to 57%-100% (Q4, MOR 1.48, 95%CI 1.44-1.51, P ≤ .001). Four percent of variance in GDMT use was explained by sites (ICC 3.9, 95%CI 2.9-5.3) and operators (ICC 4.1, 95%CI 3.1-5.4). A dose-response relationship was noted between lower GDMT rates and increased risk of 90-day readmission risk by sites (P = .021) and operators (P < .001). Lower GDMT prescription by site was associated with higher risk of 24-month mortality (HR = 1.07, 95%CI 1.02-1.13) and major amputation (HR = 1.08, 95%CI 1.01-1.15). Similar associations were found for GDMT use by provider (mortality HR = 1.05, 95%CI 1.02-1.08 and amputation HR = 1.04, 95%CI 1.00-1.08). Both at the operator and health system level, there was significant variability in GDMT prescription following PVI, proportionally translating into risk for readmission, mortality, and major amputation. Targeted quality efforts should prioritize both operator and site levels to improve GDMT use and outcomes for patients undergoing PVI.

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.

Eliminating Health Disparities in Atrial Fibrillation, Heart Failure, and Dyslipidemia: A Path Toward Achieving Pharmacoequity.

Pharmacoequity refers to the goal of ensuring that all patients have access to high-quality medications, regardless of their race, ethnicity, gender, or other characteristics. The goal of this article is to review current evidence on disparities in access to cardiovascular drug therapies across sociodemographic subgroups, with a focus on heart failure, atrial fibrillation, and dyslipidemia. Considerable and consistent disparities to life-prolonging heart failure, atrial fibrillation, and dyslipidemia medications exist in clinical trial representation, access to specialist care, prescription of guideline-based therapy, drug affordability, and pharmacy accessibility across racial, ethnic, gender, and other sociodemographic subgroups. Researchers, health systems, and policy makers can take steps to improve pharmacoequity by diversifying clinical trial enrollment, increasing access to inpatient and outpatient cardiology care, nudging clinicians to increase prescription of guideline-directed medical therapy, and pursuing system-level reforms to improve drug access and affordability.

Impact of the role of cardiology pharmacy specialist on the improvement of quality indicators among patients with heart failure and reduced ejection fraction

Abstract Background 2021 European Society of Cardiology quality indicators (QIs) for the care and outcomes of adults contains a domain for patients with heart failure with reduced ejection fraction (HFrEF) for initial treatment of guideline-directed medical therapy (GDMT) which includes beta-blocker (BB), angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-neprilysin receptors inhibitors (ARNI), mineralocorticoid receptor antagonist (MRA), and sodium-glucose transporter-2 inhibitor (SGLT2i). The QIs for the individual GDMT is estimated by finding the proportion of patients with HFrEF who are prescribed each therapy in the absence of any contraindication. Purpose To identify the role of the board certified cardiology pharmacist (BCCP) on improving the quality indicators regarding the prescribing of GDMT among patients with HFrEF during hospitalization and before discharge. Methods A cross-sectional study was conducted at the cardiac care unit in a single heart center in Iraq between January 2021 to February 2023. Among the multidisciplinary team member at this unit is a BCCP who suggests optimization of medical therapy based on the recommendations of updated European or American guidelines for the management of different cardiovascular diseases including HFrEF. The suggestion then discussed with the cardiologists for agreement. The study included the medical records for patients with HFrEF and BCCP interventions whether the interventions regarding GDMT or other medical therapy interventions. Data were reviewed and were analyzed to identify the specific interventions related to the initiation of one or more GDMT in each patients. Results Among 164 patients with HFrEF with BCCP interventions, there were 102 (62%) patients who were eligible for one or more of the GDMTs prescription which was suggested by BCCP. The most GDMT initiated was MRA 53 (43%) among 123 interventions and in 53 (52%) of 102 patients (Figure 1). QIs were improved (100%) for BB, ACEI/ARNI, MRA, and SGLT2i among eligible patients as shown in table 1. Conclusions The role of BCCP is essential among heart team for improving QIs related to the GDMT prescription among patients with HFrEF based on the recommendations of the updated guidelines. BCCP mainly improved the QIs for the prescription of MRA.Frequency of GDMT Initiation by BCCPGDMT Initiation Reflecting Improved QIs

The impact of outpatient pharmacological optimization on echocardiographic parameters in heart failure with reduced ejection fraction

Abstract Background The 2022 landmark STRONG-HF study demonstrated that aggressive uptitration of guideline directed medical therapy (GDMT) in patients recently hospitalized for heart failure leads to a reduction in the composite endpoint of heart failure hospitalization and mortality. However, the impact of optimization of GDMT on echocardiographic parameters in heart failure with reduced ejection fraction (HFrEF) is unknown. Purpose This goal of this study was to determine the impact of a virtual HFrEF optimization program for achieving GDMT uptake and its impacts of echocardiographic parameters. Methods We conducted a single center study at a Canadian community cardiovascular centre using a prospective pre-post design. NYHA class II/III HFrEF patients referred from inpatient and outpatient settings were enrolled in our virtual 3-month HFrEF optimization program. All participants underwent an initial consult with a nurse and cardiologist. After this, all patients were seen remotely by a nurse every two weeks for adjustment of HFrEF medications with the goal of maximally tolerated GDMT dosing within 3 months was. Transthoracic echocardiograms were performed prior to participation in the program &amp; after completion. Results Over 9 months, 284 NYHA class II/III HFrEF patients enrolled in the virtual HFrEF optimization program. Mean age was 67 and 70% were male. Mean ejection fraction was 34% and 54% had New York Heart Association Class II symptoms. At intake, the proportion of patients prescribed each class of GDMT was: 69% for Beta-blockers, 23% for Mineralocorticoid Receptor Inhibitors (MRA), 16% for Valsartan-Sacubitril and 7% for SGLT2 inhibitors. At 3-month follow-up, rates of GDMT prescription were improved: 90% for beta-blockers (p&amp;lt;0.01), 71% for MRA (p&amp;lt;0.01), 95% for ARNI (p&amp;lt;0.01) and 79% for SGLT2i (p&amp;lt;0.01). From baseline to follow-up echocardiogram, mean Left Ventricular End Diastolic Diameter improved from 5.51 to 5.13 cm (p&amp;lt;0.01). Mean Left Ventricular End Systolic Diameter improved from 4.33 to 3.75 cm (p&amp;lt;0.01). Mean Left Ventricular Mass Index was improved from 112.5 to 102.5 g/m2 (p&amp;lt;0.01). Mean Left Ventricular Ejection Fraction improved 34.4% to 49.8% (p&amp;lt;0.01). No hospitalizations due to medication-related adverse events were reported and 18 patients were hospitalized for HF exacerbation during study follow-up. Mean serum creatinine increased from 97.4 to 104.5 µmol/L (p&amp;lt;0.01); mean serum potassium increased from 4.48 to 4.58 (p&amp;lt;0.01). Conclusions This study demonstrates that a virtual program for GDMT optimization can safely and rapidly promote uptake of therapy in HFrEF patients. Furthermore, medical optimization was associated with significant reductions in left ventricular size, mass and ejection fraction. This provides a structural explanation for reductions in morbidity and mortality seen in STRONG-HF. Future studies should examine the effect of similar interventions on patient outcomes in a randomized setting.

Clinician perceptions and reasons for non-use of guideline-directed medical therapy for heart failure with reduced ejection fraction in the United States

Abstract Background Despite evidence that guideline-directed medical therapy (GDMT) improves outcomes in heart failure with reduced ejection fraction (HFrEF), many eligible patients remain untreated in the United States (US). Purpose To explore reasons why patients are not receiving GDMT and physician perceptions in management of their patients. Methods We conducted a cross-sectional survey of HF treatment practices (Adelphi Real World Heart Failure Disease Specific Programme) between August 2022 and February 2023, following publication of the 2022 US HF guidelines recommended that patients with HFrEF receive: angiotensin receptor/neprilysin inhibitors (ARNI), beta-blocker, mineralocorticoid receptor antagonists (MRA), and SGLT-2 inhibitors (SGLT2i). A total of 63 cardiologists and 39 primary care physicians in the US provided clinical and treatment patterns data on adult patients with HFrEF (ejection fraction ≤ 40%) and completed an attitudinal survey detailing reasons for treatment initiation. Results The study group included 323 patients with HFrEF (median age of 67 years [IQR 56-74]; 39% females) of which 59.4% were White, 19.8% African American and 9.6% Hispanic; half of the sample was insured by Medicare (50.2%), followed by commercial insurance (36.5%). GDMT prescription rates are presented in Table 1. Overall, 57.3% were not prescribed ARNI (185/323), 16.4% (53/323) were not prescribed a beta-blocker; 71.5% (231/323) were not prescribed MRA, and 65.3% (211/323) were not prescribed SGLT2i. Among patients not receiving GDMT, the most frequently reported physician reason for not prescribing ARNIs (54.1%), beta-blockers (43.4%), MRAs (54.5%) or SGLT-2is (53.6%) was physician deemed the patient to be clinically stable (Table 2). Most physicians (93.5%) reported being satisfied with treatment for patients with HFrEF and most (80.3%) believed that their patients with HFrEF were fully compliant with their treatments. Most physicians (91.2%) stated that they based their treatment decisions on both clinical experience and laboratory tests, as opposed to laboratory tests/imaging only (9.8%) or personal judgement only (16.7%). Conclusions In this cohort of patients with HFrEF from the US, the most common primary reason physicians reported for their patients not receiving GDMT was that the patient was clinically stable. Patient medication costs, contraindications, and proven intolerance were each reported as primary reasons for non-treatment in only a small minority of cases. These data suggest a strong culture of clinical inertia and lack of therapeutic urgency as the dominant driver of large gaps in use of GDMT in the US.GDMT prescriptions in HFrEF (n = 323)Physician-reasons for no GDMT

Abstract 16337: Guideline-Directed Medical Therapy Use and Association With Outcomes Among Hospitalized Heart Failure With Reduced Ejection Fraction Patients During COVID-19

Background: The association of prior to admission guideline-directed medical therapy (GDMT) with outcomes among patients hospitalized with Heart Failure with Reduced Ejection Fraction (HFrEF) and COVID-19, as well as overall GDMT prescription patterns during the pandemic, is not well known. Methods: HFrEF patients (left ventricular ejection fraction ≤40%) admitted with acute decompensated heart failure (ADHF) were identified from the American Heart Association’s Get With The Guidelines Heart Failure Registry. We analyzed the association of prior to admission GDMT use with odds of in-hospital mortality, and with odds of severe COVID-19, using adjusted logistic regression models. GDMT was defined as prescription of angiotensin converting enzyme inhibitor/angiotensin II receptor blocker/angiotensin receptor-neprilysin inhibitor (ACEI/ARB/ARNI), beta blocker (BB), or mineralocorticoid receptor antagonist (MRA). We further evaluated GDMT prescription trends during the pandemic. Results: We identified 23,899 HFrEF patients admitted with ADHF (2/16/20-3/24/21) during the pandemic, of which 333 had a diagnosis of COVID-19. We also identified 26,459 HFrEF patients admitted with ADHF in the year prior to the pandemic (2/16/19-2/15/20). Prior to admission ACEI/ARB/ARNI, BB, or MRA use was not associated with odds of in-hospital mortality or severe COVID-19. Among all HFrEF patients, prior to admission ACEI/ARB/ARNI and BB use was lower during the pandemic compared to the year prior (Figure 1, Panel A). Prior to discharge prescription of ACEI/ARB/ARNI, MRA, and triple therapy (ACEI + BB + MRA) was higher during the pandemic compared to the year prior (Figure 1, Panel B). Conclusion: Among patients with HFrEF admitted with ADHF and COVID-19, prior to admission GDMT use was not associated with in-hospital mortality or severe COVID-19. GDMT prescription rates at discharge were similar to or improved during the pandemic compared with the preceding year.

Abstract 18643: An Index to Measure Inequity-Health Equity Index for Guideline Directed Medical Therapy Among HFrEF

Background: Heart failure affects 6.2 million adults in the US with 50% five-year mortality. Effectiveness of guideline-directed medical therapy (GDMT), composed by four different medications, has been established to reduce morbidity and mortality for heart failure with reduction ejection fraction (HFrEF), and with strong incremental impact of number of GDMT medications. Despite immense positive evidence, &lt; 5% of patients with HFrEF are on the appropriate target doses of all 4 GDMTs, and there is substantial disparity of GDMT use among race/ethnic groups or socio-economical levels. However, the study to quantify the inequity of GDMT prescription is lacking. Hypothesis: Significant inequity exists in the GDMT prescription among HFrEF. Aims: We derived a health equity index (HEI) for GDMT prescription for HFrEF patients to provide administrators with an assessment tool for evaluating disparity of GDMT use at a large healthcare system covering diverse geographic areas and population in northern California. Methods: HEI for GDMT (3+ GDMT medications) is estimated by ratio of observed-to-expected values. The number of expected patients with 3+ GDMT medication level was derived from a weighted average of subpopulation distribution of the 3+ GDMT prescription for each race/ethnicity and medium income race/medium income level within the population catchment area. Observed 3+ GDMT use was captured from the medication order data in the EHR. HEI &gt; 1.0 represents existence of health inequity. We applied this method to the whole HFrEF population, and then to each of geographic area where the race/ethnicity and medium income level vary significantly. Results: Among 45,222 HFrEF patients 24.6% had 3+ GDMTs, varying from 19% to 29% in 6 geographic areas. The HEI for the whole HFrEF population was 1.33. Further analysis revealed that highest disparity occurred at East Bay area (Oakland area) (1.67), serving large proportion of non-Hispanic Black patient population, and lowest at Palo Alto area (1.27). Conclusion: HEI for GDMT reflects disparity in receiving adequate care for HFrEF population. Substantial disparity was observed in different geographic areas, implying the priority of delivering equitable care to HFrEF should start with the area with highest disparity.

Abstract 18973: Regional Differences in Optimization of Medical Therapy for Heart Failure With Reduced Ejection Fraction: Data From the HF-OPT Trial (Heart Failure Optimization Trial)

Background: Society guidelines for the optimization of guideline-directed medical therapy (GDMT) in patients with heart failure (HF) are almost identical between the United States (US) and Europe (EU). While GDMT has helped to improve survival and reduce HF hospitalization in this population, the initiation as well as titration to target doses shown to be safe and effective in clinical trials has been suboptimal. Purpose: The objective of this analysis was to assess regional differences in GDMT prescription in the United States (US) vs. Europe (EU) between 2017 and 2022.Methods: Medication data from patients (pts) with newly diagnosed heart failure with reduced ejection fraction (HFrEF) during wearable cardioverter-defibrillator use was collected from 487 pts (54% from US, 72% male, age 59±13 years). Target dose of GDMT was defined as the lowest maximum dose from either the ESC or ACC/AHA/HFSA guidelines. ACE-I/ARB/ARNI (AAA), beta blockers (BB), and mineralocorticoid receptor antagonists (MRA), were the main GDMT options for HFrEF patients at the time of HF-OPT. Association between medication with region and gender were assessed using logistic regression. Results: Compared to patients in the US, EU (Germany, Austria, France) pts were significantly more likely to receive ACE-I/ARB/ARNI and MRA and to achieve target doses by 90 and 180 days (p&lt;0.01). Interestingly, ARNI prescription rates did not differ between US and EU (39% and 47%, p=0.09) by 180 days, although target doses were more likely to be reached in the EU by 180 days (23% vs. 12%, p&lt;0.01). In contrast, rates of BB use and achieving target doses did not differ between regions (Figure). Finally, pts in the EU were more likely to receive all three medication classes by 180 days (80% vs 42%, p&lt;0.001), and more likely to be prescribed target doses of all three medications (12% vs. 7%, p&lt;0.05). After adjusting for region, there was no difference in gender for day 90 and 180 prescriptions and target doses for BB, AAA, and MRA.Conclusions: Adherence to GDMT was superior in the EU compared to the US with regards to ACE-I/ARB/ARNI and MRA. There was no difference in BB use between regions. Target dosage rates, however, were overall low in both regions.