Guideline-directed Medical Therapy Prescription Research Articles

Abstract 17432: Utilization of Heart Failure Therapies: Assessing Trends and Adoption of Updated Guideline Directed Medical Therapy Following the 2022 Heart Failure Guideline Release

Introduction: The adoption rate of new guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) is unclear. Thus, we assessed temporal trends in GDMT prescription following the release of the 2022 ACC/AHA heart failure guidelines. Methods: Using the TriNetX database, we identified HFrEF patients with an EF = 40%. Seven 2-month time windows between April 1, 2022 and May 31, 2023 were analyzed. Treatment categories included sacubitril (proxy variable for angiotensin receptor/neprilysin inhibitor), angiotensin-converting enzyme inhibitors (ACEi), beta blockers, mineralocorticoid-receptor antagonists, sodium glucose transport 2 inhibitors (SGLT2i), isosorbide dinitrate, ivabradine, hydralazine, and ICD/CRT. Incidence rate and prevalence of GDMT prescription were assessed over 14 months post-guideline publication. Results: Analysis included 167,740 HFrEF patients. Sacubitril prevalence doubled between 2022 (18.326%) and 2023 (36.779%), with a higher rate of increase after January 2023. ARB prescription prevalence increased from 39.031% to 58.696%, with notable incidence growth after January 2023. Prevalence of SGLT2i prescription increased from 14.794% in 2022 to 34.14% in 2023. Incidence rates for other therapies also showed upward trends, resulting in increased overall therapy prevalence. Slightly lower 1-month hospitalization (46.378% vs 46.654%) and mortality (7.327% vs 7.549%) were observed in the 14 months after guideline publication compared to the 14 months prior. Conclusions: Improved adherence to GDMT guidelines has occurred since the release of the 2022 guidelines. Notably, utilization of ARNIs and SGLT2 inhibitors significantly increased. However, prescription rates for these novel therapies were below 50%, highlighting the need to expand access to a larger proportion of HFrEF patients.

Abstract 17034: Outpatient Effort to Improve Medication Uptitration and Maintenance (OPTIMUM)

Introduction: Guideline-directed medical therapy (GDMT) reduces morbidity and mortality for patients with heart failure with reduced ejection fraction (HFrEF) starting as early as 30-days from initiation. Rapid GDMT titration programs have been shown to be effective in clinical trials. We evaluated the feasibility of a rapid GDMT clinical program in a safety-net population with HFrEF. Methods: Patients admitted to a large urban safety net hospital with newly diagnosed HFrEF (LVEF <40%) were eligible for the program. Patients with end-stage renal disease, history of cardiogenic shock, or current homelessness were excluded. The 6-week program consisted of alternating in-person heart failure clinic visits and virtual visits with a multidisciplinary team of pharmacists, nurses, and physicians to adjust medications and to provide heart failure education. Intensities of GDMT prescription at the start of the program and at 3 months were compared using an institutional GDMT score ranging from 0-11 which accounts for drug classes (beta-blocker, ACE/ARB/ARNI, MRA, SGLT2i) and percent of target doses prescribed (Figure, panel A). Results: This pilot enrolled 20 patients (mean age 58.0 +/- 15.6 years, 35% women, 25% Black, 75% Hispanic). At enrollment, patients had an average GDMT score of 5.5 on 2.9 classes of GDMT. At week 6, 15 (75%) patients were prescribed all 4 classes of GDMT with a 2.7 increase in the GDMT score for an average score of 8.2 (Figure, panel B).This was sustained at 3 months. There were no safety events requiring ED visits or hospitalization during the program duration. Conclusions: In a safety-net health system caring for the urban poor, rapid GDMT up titration was feasible and resulted in increased GDMT intensity without clinical adverse events. Our experience supports the development of rapid GDMT titration programs even in clinical settings and patient populations which differ from those enrolled in clinical trials.

Association Between Race, Cardiology Care, and the Receipt of Guideline-Directed Medical Therapy in Peripartum Cardiomyopathy.

Black patients with peripartum cardiomyopathy (PPCM) have disproportionately worse outcomes than White patients, possibly related to variable involvement of cardiovascular specialists in their clinical care. We sought to determine whether race was associated with cardiology involvement in clinical care during inpatient admission and whether cardiology involvement in care was associated with higher claims of guideline-directed medical therapy (GDMT) a week after hospital discharge. Using Optum's de-identified Clinformatics® Data Mart (CDM), we included Black and White patients' first hospital admission for PPCM from 2008 to 2021. Cardiology involvement in clinical care was defined as the receipt of attending care from a cardiovascular specialist during admission. GDMT included beta-blockers (BB) for all patients and triple therapy (BB, angiotensin-responsive medications, and mineralocorticoid receptor antagonists) for non-pregnant patients. Logistic regression was used to determine the associations between cardiology involvement in clinical care during admission and (1) patient race and (2) GDMT prescription, adjusting for age and comorbidities. Among 668 patients (32.6% Black, 67.4% White, 93.3% commercially insured), there was no significant difference in the odds of cardiology involvement in clinical care by race (aOR: 1.41; 95%CI: 0.87-2.33, P=0.17). Inpatient cardiology care was associated with 2.75 times increased odds of having a prescription claim for GDMT (BB) for White patients (aOR: 2.75; 95%CI 1.50-5.06, P=0.001), and the estimated effect size was similar but not statistically significant for Black patients (aOR: 2.20, 95% CI, 0.84-5.71, P=0.11). The interaction between race and cardiology involvement in clinical care was not statistically significant for the receipt of BB prescription. Among 274 non-pregnant patients with PPCM (37.2% Black, 62.8% White), 5.8% received triple GDMT. Of these, none of the Black patients lacking cardiology care had triple GDMT. However, cardiology involvement in care was not significantly associated with triple GDMT for either race. Among a commercially insured population within PPCM, race was not associated with cardiology involvement in clinical care during hospitalization. However, cardiology involvement in care was associated with significantly higher odds of prescription claims for BB for only White patients. Additional strategies are needed to support equitable GDMT prescription.

Impact of COVID-19 on heart failure hospitalization and outcome in India – A cardiological society of India study (CSI–HF in COVID 19 times study – “The COVID C–HF study”)

ObjectivesThe presentation and outcomes of acute decompensated heart failure (ADHF) during COVID times (June 2020 to Dec 2020) were compared with the historical control during the same period in 2019. MethodsData of 4806 consecutive patients of acute HF admitted in 22 centres in the country were collected during this period. The admission patterns, aetiology, outcomes, prescription of guideline-directed medical therapy (GDMT) and interventions were analysed in this retrospective study. ResultsAdmissions for acute heart failure during the pandemic period in 2020 decreased by 20% compared to the corresponding six-month period in 2019, with numbers dropping from 2675 to 2131. However, no difference in the epidemiology was seen. The mean age of presentation in 2019 was 61.75 (±13.7) years, and 59.97 (±14.6) years in 2020. There was a significant decrease in the mean age of presentation (p = 0.001). Also. the proportion of male patients decreased significantly from 68.67% to 65.84% (p = 0.037). The in-hospital mortality for acute heart failure did not differ significantly between 2019 and 2020 (4.19% and 4.,97%) respectively (p = 0.19). The proportion of patients with HFrEF did not change in 2020 compared to 2019 (76.82% vs 75.74%, respectively). The average duration of hospital stay was 6.5 days. ConclusionThe outcomes of ADHF patients admitted during the Covid pandemic did not differ significantly. The length of hospital stay remained the same. The study highlighted the sub-optimal use of GDMT, though slightly improving over the last few years.

Polypill Eligibility for Patients with Heart Failure with Reduced Ejection Fraction in the ASIAN-HF Registry: A Cross-Sectional Analysis.

The rates of guideline-directed medical therapy (GDMT) prescription for heart failure with reduced ejection fraction (HFrEF) in Asia remain sub-optimal. The primary objective of this study was to examine HFrEF polypill eligibility in the context of measured baseline prescription rates of individual components of GDMT among participants with HFrEF in Asia. A retrospective analysis of 4,868 patients with HFrEF from the multi-national ASIAN-HF registry was performed, and 3,716 patients were included in the final, complete case analysis. Eligibility for a HFrEF polypill, upon which patients were grouped and characterized, was based on the following: left ventricular systolic dysfunction (LVEF < 40% on baseline echocardiography), systolic blood pressure ≥ 100 mm Hg, heart rate ≥ 50 beats/minute, eGFR ≥ 30 mL/min/1.73 m, and serum potassium ≤ 5.0 mEq/L. Regression analyses were performed to evaluate associations of the baseline sociodemographic factors with HFrEF polypill eligibility. Among 3,716 patients with HFrEF in the ASIAN-HF registry, 70.3% were eligible for a HFrEF polypill. HFrEF polypill eligibility was significantly higher than baseline rates of triple therapy prescription of GDMT across sex, all studied geographical regions, and income levels. Patients were more likely to be eligible for a HFrEF polypill if they were younger and male, with higher BMI and systolic blood pressure, and less likely to be eligible if they were from Japan and Thailand. The majority of patients with HFrEF in ASIAN-HF were eligible for a HFrEF polypill and were not receiving conventional triple therapy. HFrEF polypills may be a feasible and scalable implementation strategy to help close the treatment gap among patients with HFrEF in Asia.

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.

Novel Strategies to Improve Prescription of Guideline-Directed Medical Therapy in Heart Failure.

To examine the emerging data for novel strategies being studied to improve use and dose titration of guideline-directed medical therapy (GDMT) for patients with heart failure (HF). There is mounting evidence to employ novel multi-pronged strategies to address HF implementation gaps. Despite high-level randomized evidence and clear national society recommendations, a large gap persists in use and dose titration of guideline-directed medical therapy (GDMT) in patients with heart failure (HF). Accelerating the safe implementation of GDMT has proven to reduce the morbidity and mortality associated with HF but remains an ongoing challenge for patients, clinicians, and health systems. In this review, we examine the emerging data for novel strategies to improve the use of GDMT including the use of multidisciplinary team-based approaches, nontraditional patient encounters, patient messaging/engagement, remote patient monitoring, and electronic health record (EHR)-based clinical alerts. While societal guidelines and implementation studies have focused on heart failure with reduced ejection fraction (HFrEF), expanding indications and evidence for the use of sodium glucose cotransporter2 (SGLT2i) will necessitate implementation efforts across the LVEF spectrum.

Abstract 15287: Optimizing Guideline Directed Medical Therapy in Recently Hospitalized Patients With Heart Failure in a Large Urban Veterans Affairs Medical Center

Introduction: A quarter of patients hospitalized for heart failure either die or are re-hospitalized within 30 days. Optimization of guideline directed medical therapy (GDMT) has been shown to decrease both mortality and hospital readmissions. Methods: We used an existing heart failure clinical dashboard registry at our Veterans Affairs (VA) hospital to determine the rates of hospitalization from any medical cause and GDMT prescription rates from November to December 2022. We performed a retrospective chart review to validate dashboard results. Results: Twenty-nine patients in the registry were hospitalized within the last 30 days, with 5 patients excluded due to ongoing hospitalization; 19 were classified as heart failure with reduced ejection fraction (HFrEF, LVEF ≤ 40%), 4 as heart failure with preserved ejection fraction (LVEF ≥ 50%), and 2 unknown (no EF in 3 years). The rates of quadruple GDMT was 16% in all heart failure patients and 21% in patients with HFrEF (table 1). We performed a root cause analysis of low GDMT rates (figure 1). We used this data to secure buy-in from hospitalist medicine and cardiology to support a full-time cardiology pharmacist to screen all currently admitted patients with HFrEF. We created a standardized note template that gives recommendations for GDMT optimization prior to discharge. Conclusions: Although there is strong evidence that GDMT improves patient outcomes, many recently hospitalized patients are not optimized even after accounting for relative contraindications. We demonstrate that using tools such as a clinical dashboard and problem visualization with quality improvement methodology can both make GDMT optimization more tangible and also create buy-in from the health system to implement change.

Predictors of in-hospital mortality due to heart failure hospitalisation and trends of guideline-directed medical therapy usage

Abstract Background The burden of heart failure (HF) is immense, from reducing quality of life (QoL) to increasing mortality risks and additional financial implications. The risk of adverse outcomes get higher with each HF hospitalisation (HFH). Purpose To look at predictors of in-hospital mortality outcomes during HFH and the prescription trends in conventional guideline-directed medical therapy (GDMT) for HF. Methods Retrospective analyses were performed for 7405 HFH cases admitted to our cardiology institution from 2009 to 2018, diagnosed based on the signs and symptoms of heart failure with NTProBNP≥300 at presentation. Results Most patients that required HFH were aged &amp;lt;65 years (53.5%), were males (72.8%) and had more diabetes mellitus (66%) and hypertension (75.1%). There were fewer other co-morbidities such as coronary artery disease (CAD) (26.9%), renal insufficiency (33.8%), atrial fibrillation (Afib) (23.9%), dyslipidaemia (40.3%), prior stroke/transient ischaemic attack (TIA) (5.6%), chronic obstructive pulmonary disease (11.6%), current/ex-smokers (45.5%). Most had presenting systolic blood pressure (SBP) &amp;gt;100 mmHg (88.8%), presenting heart rate ≥70 bpm (78.6%) and were in heart failure with reduced ejection fraction (HFrEF) &amp;lt;40% (74.8%). At presentation for HFH, 31.2% had 3 GDMTs (GDMT III) (angiotensin converting enzyme inhibitor / angiotensin receptor blocker / angiotensin receptor neprilysin inhibitor + beta blocker + mineralocorticoid receptor antagonist), 37% had either 2 GDMTs (GDMT II), 25% had only 1 GDMT (GDMT I), while 6.8% had none. The average in-hospital mortality rate was 5.2%. Independent predictors associated with increased in-hospital mortality were males, renal insufficiency, Afib, prior stroke/TIA, SBP ≤100 mmHg, serum sodium &amp;lt;135 mmol/L, uric acid ≥529 μmol/L, NTProBNP ≥6590, inpatient procedures i.e. dialysis, mechanical ventilation and cardiopulmonary resuscitation (CPR). Independent predictors associated with reduced inpatient mortality were hypertension, inpatient cardiac diagnostic procedures and presence of GDMT I, GDMT II and GDMT III at presentation (Figure 1). Throughout the 10 years, the proportion of GDMT prescription were similar; GDMT I (19.1–28.7%), GDMT II (35.1–41.6%), GDMT III (25.2–37.3%). The proportion of GDMT III across the CKD group stages were never more than 50% (Figure 2). Conclusion There remains significant in-hospital mortality risk for HFH. While some of these predictors are not modifiable, others are, especially when it comes to GDMT prescriptions. GDMTs provide better prognosis in patients living with HF. There are growing evidence that simultaneous / rapid sequence initiation of GDMTs are more beneficial than the conventional step wise approach. The analysis findings of GDMT proportions at presentation of HFH and also in the CKD group stages meant that many patients are still receiving suboptimal care for their HF and this clinician inertia mentality has got to change. Funding Acknowledgement Type of funding sources: None.

Maximally tolerated guideline-directed medical therapy and barriers to optimization in patients with heart failure with reduced ejection fraction: the COAPT trial

Abstract Background The COAPT trial of MitraClip therapy employed a central screening eligibility committee (CSEC) of heart failure (HF) experts to ensure the use of maximally tolerated guideline-directed medical therapy (GDMT) and systematically document intolerances in all potential patients prior to approval for randomization. Purpose To describe the percentage of GDMT classes, doses tolerated, predictors of intolerance, and specific intolerances limiting GDMT among patients approved for randomization by the CSEC. Methods We analyzed baseline use, dose, and intolerances of i) angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB) or angiotensin receptor neprilysin inhibitor (ARNI); ii) beta-blockers (BB); and iii) mineralocorticoid receptor antagonists (MRA) in the CSEC-approved COAPT population with HF with reduced ejection fraction (HFrEF; LVEF ≤40%). We analyzed variables associated with GDMT tolerance. Results In COAPT, 464 patients had HFrEF and complete screening medication information. Any dose of all 3, 2 or 1 GDMT classes were tolerated in 39%, 39% and 20% of patients respectively; only 2% of patients (n=9) could not tolerate any GDMT (Figure 1). BB were prescribed in the most (93%) patients followed by ACEI/ARB/ARNI (69%) and MRA (55%). Intolerances limiting each GDMT class differed, but hypotension and kidney dysfunction were most common (Figure 2). No patients tolerated goal doses of all 3 GDMT classes. For BB, only 32% tolerated ≥50% of the goal dose; while for ACEI/ARB/ARNI, no patients achieved goal doses, and only 1% tolerated ≥50% of the goal dose. For MRA, 86% of patients tolerated 25mg/day or less. Patients intolerant of BB were less likely to tolerate an ACEI/ARB/ARNI (OR 0.39, 95% CI 0.20–0.76; p=0.004) but not a MRA (p=0.21) compared with patients tolerating a low dose BB. Patients intolerant of MRA were less likely to tolerate ACEI/ARB/ARNI therapy (OR 0.37, 95% CI 0.25–0.57; p&amp;lt;0.0001) but not a BB (p=0.31) compared with patients tolerating MRA. Patients tolerating low dose ACEI/ARB/ARNI had a higher baseline mean eGFR (52±21 versus 40±21 ml/min/m2; p&amp;lt;0.0001) compared with patients intolerant of ACEI/ARB/ARNI. Likewise, patients tolerating MRA had a higher baseline mean eGFR (52±21 versus 42±21 ml/min/m2; p&amp;lt;0.0001) compared with patients intolerant of MRA. Conclusion In a contemporary trial in which HF specialists ensured GDMT optimization, many patients had medical intolerances prohibiting use of one or more GDMT classes, and few patients tolerated target doses. These findings indicate medical intolerances are the primary cause of low GDMT prescription rates in patients with moderate to severe HFrEF. Yet, use of GDMT in this very ill population was much better than “real world” registries of HFrEF suggesting that mandating careful CSEC review prior to study enrollment is important for clinical trials having the objective of randomizing a maximally treated patient cohort. Funding Acknowledgement Type of funding sources: None.

ADHERENCE TO GUIDELINE-DIRECTED MEDICAL THERAPY AMONG PATIENTS FOLLOWED AT AN AMBULATORY HEART FUNCTION CLINIC

ADHERENCE TO GUIDELINE-DIRECTED MEDICAL THERAPY AMONG PATIENTS FOLLOWED AT AN AMBULATORY HEART FUNCTION CLINIC

Guideline-directed medical therapy in patients undergoing transcatheter edge-to-edge repair for secondary mitral regurgitation.

Guideline-directed medical therapy (GDMT), based on the combination of beta-blockers (BB), renin-angiotensin system inhibitors (RASI), and mineralocorticoid receptor antagonists (MRA), is known to have a major impact on the outcome of patients with heart failure with reduced ejection fraction (HFrEF). Although GDMT is recommended prior to mitral valve transcatheter edge-to-edge repair (M-TEER), not all patients tolerate it. We studied the association of GDMT prescription with survival in HFrEF patients undergoing M-TEER for secondary mitral regurgitation (SMR). EuroSMR, a European multicentre registry, included SMR patients with left ventricular ejection fraction <50%. The outcome was 2-year all-cause mortality. Of 1344 patients, BB, RASI, and MRA were prescribed in 1169 (87%), 1012 (75%), and 765 (57%) patients at the time of M-TEER, respectively. Triple GDMT prescription was associated with a lower 2-year all-cause mortality compared to non-triple GDMT (hazard ratio [HR] 0.74; 95% confidence interval [CI] 0.60-0.91). The association persisted in patients with glomerular filtration rate <30 ml/min, ischaemic aetiology, or right ventricular dysfunction. Further, a positive impact of triple GDMT prescription on survival was observed in patients with residual mitral regurgitation of ≥2+ (HR 0.62; 95% CI 0.44-0.86), but not in patients with residual mitral regurgitation of ≤1+ (HR 0.83; 95% CI 0.64-1.08). Triple GDMT prescription is associated with higher 2-year survival after M-TEER in HFrEF patients with SMR. This association was consistent also in patients with major comorbidities or non-optimal results after M-TEER.

Improving heart failure care and guideline-directed medical therapy through proactive remote patient monitoring-home telehealth and pharmacy integration

To address ambulatory care sensitive hospitalisations in heart failure (HF), we implemented a quality improvement initiative to reduce admissions and improve guideline-directed medical therapy (GDMT) prescription, through proactive integration of...

Multimorbidity, guideline‐directed medical therapies, and associated outcomes among hospitalized heart failure patients

AimsMultimorbidity is common among heart failure (HF) patients and may attenuate guideline‐directed medical therapy (GDMT). Multimorbid patients are under‐represented in clinical trials; therefore, the effect of multimorbidity clustering on the prognosis of HF patients remains unknown. We evaluated the prevalence of multimorbidity clusters among consecutively registered hospitalized HF patients and assessed whether GDMT attenuated outcomes.Methods and resultsWe examined 1924 hospitalized HF patients with reduced left ventricular ejection fraction (<50%) in a multicentre registry (West Tokyo HF Registry: WET‐HF). Ten comorbid conditions in the WET‐HF were abstracted: coronary artery disease, atrial fibrillation, stroke, anaemia, chronic obstructive pulmonary disease, renal dysfunction, obesity, hypertension, dyslipidaemia, and diabetes. Patients were divided into three groups (0–2: n = 451; 3–4: n = 787; and ≥5: n = 686) based on the number of comorbid conditions. The primary composite endpoint was all‐cause mortality and HF rehospitalization. The most prevalent comorbidities were renal dysfunction (67.9%), hypertension (66.0%), and anaemia (53.8%). Increased comorbidity was associated with increased adverse outcomes [3–4: hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.13–1.77, P = 0.003; ≥5: HR 2.12, 95%CI 1.69–2.65, P < 0.001; and reference: 0–2] and lower GDMT prescription rate (0–2: 69.2%; 3–4: 57.7%; and ≥5: 57.6%). GDMT was associated with decreased adverse outcomes; this association was maintained even as the comorbidity burden increased but tended to weaken (0–2: HR 0.53, 95%CI 0.35–0.78; P = 0.001; 3–4: HR 0.82, 95%CI 0.65–1.04, P = 0.095; and ≥5: HR 0.81, 95%CI 0.65–1.00, P = 0.053; P for interaction = 0.156).ConclusionsComorbidity clusters were prevalent and associated with poorer outcomes. GDMT remained beneficial regardless of the comorbidity burden but tended to weaken with increasing comorbidity burden. Further research is required to optimize medical care in these patients.

Multimorbidity And Guideline-Directed Medical Therapy Intensification In Heart Failure: Findings From The EPIC-HF Trial

<h3>Background</h3> Despite proven benefits of guideline directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF), multiple studies have shown that rates of GDMT prescribing are suboptimal worldwide. An important potential contributor to suboptimal GDMT is the high burden of multimorbidity in the HFrEF population, with estimates showing at least 50% of patients having 5+ co-occurring chronic conditions and taking 10+ medications daily. Large registries examining GDMT prescribing demonstrate associations between individual co-morbidities and GDMT, but data is lacking on the cumulative effect of multimorbidity on GDMT prescription. <h3>Methods</h3> The recently completed 3-site EPIC-HF trial tested the effect of a pre-clinic patient activation tool on GDMT prescribing made following a visit with a cardiology provider and then over the subsequent 6 months. Using this data, we examined the effect of multimorbidity on both baseline GDMT prescription and GDMT initiation and dose intensification (the primary outcome of the EPIC-HF trial). Presence of the following 9 co-morbidities was collected: COPD or other pulmonary disease, liver disease, diabetes, cancer (excluding non-melanoma skin cancer), depression, anxiety or other psychiatric disease, atrial fibrillation or flutter, hypertension, CKD (eGFR <= 60), and obesity (BMI>=30). <h3>Results</h3> Of the 292 patients, 35.6% had 3 or more non-HFrEF comorbidities and 34.6% had 1 or fewer additional comorbidities. The most commonly occurring comorbidities were hypertension (51.7%), obesity (41.4%), CKD (32.9%), diabetes (25%) and atrial fibrillation or flutter (28.1%). Increasing burden of multimorbidity was not associated with less total prescription of GDMT at baseline, and was, in fact, associated with the prescription of higher doses of beta-blocker (median 50% target dose with 3+ additional comorbidities vs 25% with no comorbidities, p=<0.01). When controlling for study arm in the original EPIC-HF trial, the presence of additional comorbidities was associated with decreased likelihood of GDMT intensification (1 comorbidity v. 0: RR 0.61, 95% CI 0.4-0.95; 2 v. 0: RR 0.88 95% CI 0.61-1.27; 3+ v. 0: RR 0.56, 95% CI 0.36-0.86). Individual comorbidities associated with decreased likelihood of GDMT intensification were diabetes (p=0.02), hypertension (p=0.003), and CKD (p=0.047). <h3>Conclusions</h3> Increasing burden of multimorbidity was not associated with less total GDMT prescription at baseline but was associated with decreased up-titration or initiation of GDMT at the study visit.

Guideline Directed Medical Therapy In A Safety Net Hospital, Where Do We Stand?

<h3>Background</h3> : Despite a clear mandate to maximize guideline directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF), large registries have shown sub-optimal rates of both prescription and uptitration. Rates of GDMT in large community safety net hospitals are not well known. Moreover, the patient population of safety net hospitals is markedly different than contemporary registries. Our aim was to create an accessible, self-maintained, electronic health record (EHR) based registry of HFrEF patients that can be leveraged to describe rates of GDMT, and support quality improvement initiatives in a large safety net hospital. <h3>Methods</h3> : Left ventricular ejection fraction (LVEF) was recently made to be a mandatory field for all transthoracic echocardiograms, which is then pulled into the EHR as a discrete field. Using this data, we enrolled all patients with an LVEF ≤ 40% from August 2019-April 2021 at Parkland Health and Hospital System, a large 860 bed safety net hospital for Dallas, Texas (n=2,624). The registry was then queried for an ICD10 diagnosis of heart failure (n=2,555, 97.3%) and patients without an ICD10 diagnosis of heart failure (n=69) were adjudicated manually. Patients with a most recent LVEF ≤ 40% (n=2,447) were queried for heart failure pharmacotherapies and doses. <h3>Results</h3> : Our registry comprises a young, male predominant cohort that is racially and ethnically diverse as seen in table 1. In figure 1a we find prescription rates of GDMT on par with national cohorts with excellent prescription rates of ARNI and SGLT2 inhibitors, particularly in the 1,417 (57.9%) who have been seen in Cardiology or CHF clinics in the last 2 years. We found that the majority of patients on GDMT are on less than 50% of the goal dose as seen in figure 1b. <h3>Conclusion</h3> : The HFrEF population in a large safety-net hospital system was a young diverse population with rates of GDMT prescription similar to national cohorts, with higher rates of ARNI and SGLT2-inhibitors. The registry provides a platform for future quality improvement initiatives to increase GDMT prescription and uptitration.

Abstract P194: Polypill Eligibility For Patients With Heart Failure With Reduced Ejection Fraction In South India: A Secondary Analysis Of A Prospective, Interrupted Time Series Study

In India, data from large HF registries has demonstrated significantly lower 5-year mortality rates for patients with HFrEF discharged on guideline-directed medical therapy (GDMT), revealing an important target for intervention to improve clinical outcomes. Hospital-based quality improvement initiatives to increase rates of GDMT at hospital discharge have had limited effect, suggesting additional strategies are needed to improve GDMT rates in HFrEF patients. Polypills for HFrEF have been proposed as an implementation strategy to simplify the current treatment paradigm for undertreated patients with HFrEF. However, the potential effect of HFrEF polypills on increasing GDMT rates in target populations is unknown. The objective of this secondary analysis is to describe eligibility for a potential HFrEF polypill in the context of GDMT prescription rates for South Indian patients with HFrEF. We analyzed data from a prospective, interrupted time series study in 2018 (HFQUIK) that evaluated the effect of a quality improvement intervention on process of care measures and clinical outcomes in patients hospitalized with acute HFrEF in 8 hospitals in South India. The primary outcome was prescription of GDMT defined as an ACE-I or ARB or ARNi, along with a beta-blocker and aldosterone antagonist. Participants were eligible for a HFrEF polypill containing GDMT if LVEF&lt;40%, HR ≥50 beats/min, creatinine ≤2.5 mg/dL in men and ≤2 mg/dL in women, and potassium &lt;5 mEq/L. We included 937 participants with HFrEF (n = 494 control period, n = 443 intervention period). Prescription rates of ACE-I or ARB or ARNi, beta-blocker, and aldosterone antagonists were low on hospital admission and increased at hospital discharge. The prescription of GDMT increased from 5.5% (27/494) to 28.8% (127/494) in the control period and from 4.5% (20/443) to 42.3% (171/443) in the intervention period. Notably, more than 80% of participants were eligible for a HFrEF polypill at hospital discharge during both control (364/494) and intervention (336/443) periods, with similar rates among female and male participants. In this study, than 80% of patients were eligible for a HFrEF polypill at discharge. Although the HF QUIK quality improvement intervention increased rates of GDMT at hospital discharge, routine administration of a HFrEF polypill could further increase this rate and improve adherence by 44% (95% CI: 26% to 65%) in a population that remains undertreated despite targeted quality improvement interventions. Availability of multiple HFrEF polypill doses could prioritize safety and tolerability with low-dose initiation and subsequent titration to higher-dose polypills. This analysis suggests a simplified polypill-based management strategy could be transformative for closing the treatment gap in HFrEF inequities in India and globally.

The Cardiology Society of India-Kerala Acute Heart Failure Registry: poor adherence to guideline-directed medical therapy.

Data on the burden of acute heart failure (AHF) admissions, practice patterns, and outcomes are rare from India and other low- and middle-income countries. We aimed to describe the baseline characteristics, guideline-directed medical therapy (GDMT) prescribing patterns and 90-day mortality rates in patients admitted with AHF in Kerala, India. The Cardiology Society of India-Kerala Acute Heart Failure Registry (CSI-KHFR) is an observational registry from 50 hospitals in Kerala, India, with prospective follow-up. Consecutive patients with AHF, who consented to participate, were enrolled. The 2016 European Society of Cardiology criteria were used for the diagnosis of AHF. Kaplan-Meier survival analysis and Cox-proportional hazard models were used for data analysis. The variables in the MAGGIC risk score were used in the multivariable model. A total of 7507 patients with AHF (37% female) participated in the CSI-KHFR. The mean age was 64.3 (12.9) years. More than two-third had reduced ejection fraction (EF) (67.5%). Nearly one-fourth (28%) of patients with heart failure (HF) with reduced EF received GDMT. Overall, in-hospital and 90-day mortality rates were 7% and 11.6%, respectively. Prescriptions of different components of GDMT were independently associated with 90-day mortality. The CSI-KHFR recorded an in-hospital and 90-day mortality of 7% and 11.6%, respectively. Only one of four patients received GDMT. AHF mortality was independently associated with GDMT initiation. Quality improvement initiatives that focus on increasing GDMT prescription may improve the survival of HF patients in India.

Abstract 10316: De-escalation of Guideline-Directed Medical Therapy in Ambulatory Heart Failure: Insights from the EPIC-HF Trial

Background: Despite proven benefits of guideline directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF), multiple studies have shown that rates of GDMT prescribing are suboptimal worldwide. The recently completed EPIC-HF trial demonstrated that a pre-clinic patient activation tool significantly increased GDMT intensification following a visit with a cardiology provider. However, whether GDMT intensification was sustained or associated with subsequent de-escalation was unknown. Methods: The EPIC-HF trial reported GDMT intensification at 1 month follow-up after the initial clinic visit. We analyzed GDMT prescription data from 1 to 6 month follow-up to examine the effect of an initial GDMT intensification by 1 month on subsequent rates of GDMT de-escalation from 1 to 6 months. Results: A total of 282 patients completed 6 month follow-up. From the study visit to 1 month follow-up, 39.7% (n=112) had an initial GDMT intensification. An initial intensification was not significantly associated with subsequent de-escalation of any GDMT medication from 1 to 6 month follow-up (24.1% de-escalated after no initial change vs 28.6% after initial intensification, p=0.40), nor was it significantly associated with de-escalation of any individual class of medication (BB 8.8% vs 11.6%, p=0.44; ACE-I 5.9% vs 8.9%, p=0.33; ARB 5.3% vs 6.3% p=0.73; MRA 6.5% vs 8.0%, p=0.62). Initial GDMT intensification was associated with dose reduction or discontinuation of loop diuretic (4.1% vs. 11.6%, p=0.02). Conclusions: Patients who had GDMT intensified at an initial visit were not significantly more likely to have a subsequent de-escalation by 6 month follow-up; however, they were more likely to have their loop diuretic down-titrated or discontinued.

Guideline-Directed Medical Therapy in Patients with Chronic Kidney Disease Undergoing Peripheral Vascular Intervention

Introduction: Guideline-directed medical therapy (GDMT) is imperative to improve cardiovascular and limb outcomes for patients with critical limb ischemia (CLI), especially amongst those at highest risk for poor outcomes, including those with comorbid chronic kidney disease (CKD). Our objective was to examine GDMT prescription rates and their variation across individual sites for patients with CLI undergoing peripheral vascular interventions (PVIs), by their comorbid CKD status. Methods: Patients with CLI who underwent PVI (October 2016–April 2019) were included from the Vascular Quality Initiative (VQI) database. CKD was defined as GFR <60 mL/min/1.73 m². GDMT included the composite use of antiplatelet therapy and a statin, as well as an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker if hypertension was present. The use of GDMT before and after the index procedure was summarized in those with and without CKD. Adjusted median odds ratios (MORs) for site variability were calculated. Results: The study included 28,652 patients, with a mean age of 69.4 ± 11.7 years, and 40.8% were females. A total of 47.5% had CKD. Patients with CKD versus those without CKD had lower prescription rates both before (31.7% vs. 38.9%) and after (36.5% vs. 48.8%) PVI (p < 0.0001). Significant site variability was observed in the delivery of GDMT in both the non-CKD and CKD groups before and after PVI (adjusted MORs: 1.31–1.41). Discussion/Conclusion: In patients with CLI undergoing PVI, patients with comorbid CKD were less likely to receive GDMT. Significant variability of GDMT was observed across sites. These findings indicate that significant improvements must be made in the medical management of patients with CLI, particularly in patients at high risk for poor clinical outcomes.