Guideline-directed Medical Therapy Utilisation Research Articles

Abstract 4113961: Contemporary Guideline Directed Medical Therapy in Heart Failure in Clinical Practice - Results from the EMPACE Study

Background: Guideline directed medical therapy (GDMT) for heart failure (HF) evolves, incorporating newer therapies such as SGLT2i within recommendations for HFmrEF and HFpEF. Understanding the contemporary profile of real-world HF patients, in combination with real-world utilization of GDMT, is important for informing GDMT implementation and quality improvement strategies. The EMPACE study aims to improve our comprehension of HF GDMT utilization in real-world settings during post-2020 . Objectives: To describe baseline demographic and clinical characteristics, including baseline treatments, of patients with HF hospitalization (HHF). Methods: This non-interventional, retrospective cohort study used patient data standardized to the OMOP Common Data Model from the Optum Market Clarity, an integrated EHR and Claims database in the U.S. The study period spanned from Jun-2020 to Oct-2023. Adult patients with a primary diagnosis of HF during hospitalization were stratified by HF phenotypes (HFrEF, HFmrEF, HFpEF) based on left ventricular ejection fraction (EF). Results: A total of 30,762 patients with HHF were included (74% HFrEF, 4% HFmrEF, and 22% HFpEF). The mean age was 70.1 years, 60% were male, mean BMI was 30.6 kg/m 2 , and mean eGFR was 58.7 mL/min/1.73m 2 . Of them, 72% had a history of HF and 43% has been previously hospitalized for HF in the past 1 year. The prevalence of baseline comorbidities was as follows: hypertension (90%), coronary artery disease (54%), chronic kidney disease (38%), atrial fibrillation (40%), peripheral artery disease (9%), stroke history (9%), and end-stage renal disease (1%). Medication prior to HF hospitalization are described in the figure 1. Overall, prior comorbidities and HF medication use in the last 365 days prior to HHF were similar between all HHF patients and the HFrEF, HFmrEF, and HFpEF phenotypes, except for the lower use of MRA and ARNI in HFmrEF, and HFpEF patients. Conclusion: This study showed a high comorbidity burden and a low utilization of many GDMT prior to hospitalization, especially for novel GDMT (ARNI and SGLT2i) and in HFmrEF and HFpEF. Despite many medications having a varying strength of guideline recommendation depending on EF, absolute differences in rates of GDMT utilization were relatively small across the EF phenotypes. Across the spectrum of EF, further efforts are needed to improve use of GDMT and reduce the missed opportunities for GDMT implementation that are occurring prior to HHF.

Guideline-directed medical therapy implementation during hospitalization for cardiogenic shock.

Despite significant morbidity and mortality, recent advances in cardiogenic shock (CS) management have been associated with increased survival. However, little is known regarding the management of patients who survive CS with heart failure (HF) with reduced left ventricular ejection fraction (LVEF, HFrEF), and the utilization of guideline-directed medical therapy (GDMT) in these patients has not been well described. To fill this gap, we investigated the use of GDMT during an admission for CS and short-term outcomes using the Inova single-centre shock registry. We investigated the implementation of GDMT for patients who survived an admission for CS with HFrEF using data from our single-centre shock registry from January 2017 to December 2019. Baseline characteristics, discharge clinical status, data on GDMT utilization and 30day, 6month and 12month patient outcomes were collected by retrospective chart review. Among 520 patients hospitalized for CS during the study period, 185 (35.6%) had HFrEF upon survival to discharge. The median age was 64years [interquartile range (IQR) 56, 70], 72% (n=133) were male, 22% (n=40) were Black and 7% (n=12) were Hispanic. Forty-one per cent of patients (n=76) presented with shock related to acute myocardial infarction (AMI), while 59% (n=109) had HF-related CS (HF-CS). The median length of hospital stay was 12days (IQR 7, 18). At discharge, the proportions of patients on beta-blockers, angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs)/angiotensin receptor/neprilysin inhibitors (ARNIs) and mineralocorticoid receptor antagonists (MRAs) were 78% (n=144), 58% (n=107) and 55% (n=101), respectively. Utilization of three-drug GDMT was 33.0% (n=61). Ten per cent of CS survivors with HFrEF (n=19) were not prescribed any component of GDMT at discharge. Multivariable logistic regression adjusted for baseline GDMT use revealed that patients with lower LVEF and those who transferred to our centre from an outside hospital were more likely to experience GDMT addition (P<0.05). Patients prescribed at least one additional class of GDMT during admission had higher odds of 6month and 1year survival (P<0.01): On average, 6month survival odds were 7.1 times greater [confidence interval (CI) 1.9, 28.5] and 1year survival odds were 6.0 times greater than those who did not have at least one GDMT added (CI 1.9, 20.5). Most patients who survived CS admission with HFrEF in this single-centre CS registry were not prescribed all classes or goal doses of GDMT at hospital discharge. These findings highlight an urgent need to augment multidisciplinary efforts to enhance the post-discharge medical management and outcomes of patients who survive CS with HFrEF.

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.

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

Heart failure medical therapy prior to mitral transcatheter edge-to-edge repair: the STS/ACC Transcatheter Valve Therapy Registry.

Guideline-directed medical therapy (GDMT) is recommended before mitral valve transcatheter edge-to-edge repair (MTEER) in patients with heart failure (HF) and severe functional mitral regurgitation (FMR). Whether MTEER is being performed on the background of optimal GDMT in clinical practice is unknown. Patients with left ventricular ejection fraction (LVEF) < 50% who underwent MTEER for FMR from 23 July 2019 to 31 March 2022 in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry were identified. Pre-procedure GDMT utilization was assessed. Cox proportional hazards models were constructed to evaluate associations between pre-MTEER therapy (no/single, double, or triple therapy) and risk of 1-year mortality or HF hospitalization (HFH). Among 4199 patients across 449 sites, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, mineralocorticoid receptor antagonists, and angiotensin receptor-neprilysin inhibitors were used in 85.1%, 44.4%, 28.6%, and 19.9% before MTEER, respectively. Triple therapy was prescribed for 19.2%, double therapy for 38.2%, single therapy for 36.0%, and 6.5% were on no GDMT. Significant centre-level variation in the proportion of patients on pre-intervention triple therapy was observed (0%-61%; adjusted median odds ratio 1.48 [95% confidence interval (CI) 1.25-3.88]; P < .001). In patients eligible for 1-year follow-up (n = 2014; 341 sites), the composite rate of 1-year mortality or HFH was lowest in patients prescribed triple therapy (23.0%) compared with double (24.8%), single (35.7%), and no (41.1%) therapy (P < .01 comparing across groups). Associations persisted after accounting for relevant clinical characteristics, with lower risk in patients prescribed triple therapy [adjusted hazard ratio (aHR) 0.73, 95% CI .55-.97] and double therapy (aHR 0.69, 95% CI .56-.86) before MTEER compared with no/single therapy. Under one-fifth of patients with LVEF <50% who underwent MTEER for FMR in this US nationwide registry were prescribed comprehensive GDMT, with substantial variation across sites. Compared with no/single therapy, triple and double therapy before MTEER were independently associated with reduced risk of mortality or HFH 1 year after intervention.

Clinical Inertia Among Outpatients With Heart Failure: Application of Treatment Nonintensification Taxonomy to EPIC-HF Trial

BackgroundThe contribution of clinical inertia to suboptimal guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF) remains unclear. ObjectivesThis study examined reasons for GDMT nonintensification and characterized clinical inertia. MethodsIn this secondary analysis of EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction), a randomized clinical trial evaluating a patient-activation tool on GDMT utilization, we performed a sequential, explanatory mixed-methods study. Reasons for nonintensification among 4 medication classes were assigned according to an expanded published taxonomy using structured chart reviews. Audio transcripts of clinic encounters were analyzed to further characterize nonintensification reasons. Integration occurred during the interpretation phase. ResultsAmong 292 HFrEF patients who completed a cardiology visit, 185 (63.4%) experienced no treatment intensification, of whom 90 (48.6%) had at least 1 opportunity for intensification of a medication class with no documented contraindication or barriers (ie, clinical inertia). Nonintensification reasons varied by medication class, and included heightened risk of adverse effects (range 18.2%-31.6%), patient nonadherence (range 0.8%-1.1%), patient preferences and beliefs (range 0.6%-0.9%), comanagement with other providers (range 4.6%-5.6%), prioritization of other issues (range 15.6%-31.8%), multiple categories (range 16.5%-22.7%), and clinical inertia (range 22.7%-31.6%). A qualitative analysis of 32 clinic audio recordings demonstrated common characteristics of clinical inertia: 1) clinician review of medication regimens without education or intensification discussions; 2) patient stability as justification for nonintensification; and 3) shorter encounters for nonintensification vs intensification. ConclusionsIn this comprehensive study exploring HFrEF prescribing, clinical inertia is a main contributor to nonintensification within an updated taxonomy classification for suboptimal GDMT prescribing. This approach should help target strategies overcoming GDMT underuse.

Racial Differences in Trends and Prognosis of Guideline-Directed Medical Therapy for Heart Failure with Reduced Ejection Fraction: the Atherosclerosis Risk in Communities (ARIC) Surveillance Study.

Racial disparities in guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) have not been fully documented in a community setting. In the ARIC Surveillance Study (2005-2014), we examined racial differences in GDMT at discharge, its temporal trends, and the prognostic impact among individuals with hospitalized HFrEF, using weighted regression models to account for sampling design. Optimal GDMT was defined as beta blockers (BB), mineralocorticoid receptor antagonist (MRA) and ACE inhibitors (ACEI) or angiotensin II receptor blockers (ARB). Acceptable GDMT included either one of BB, MRA, ACEI/ARB or hydralazine plus nitrates (H-N). Of 16,455 (unweighted n = 3,669) HFrEF cases, 47% were Black. Only ~ 10% were discharged with optimal GDMT with higher proportion in Black than White individuals (11.1% vs. 8.6%, p < 0.001). BB use was > 80% in both racial groups while Black individuals were more likely to receive ACEI/ARB (62.0% vs. 54.6%) and MRA (18.0% vs. 13.8%) than Whites, with a similar pattern for H-N (21.8% vs. 10.1%). There was a trend of decreasing use of optimal GDMT in both groups, with significant decline of ACEI/ARB use in Whites (- 2.8% p < 0.01) but increasing H-N use in both groups (+ 6.5% and + 9.2%, p < 0.01). Only ACEI/ARB and BB were associated with lower 1-year mortality. Optimal GDMT was prescribed in only ~ 10% of HFrEF patients at discharge but was more so in Black than White individuals. ACEI/ARB use declined in Whites while H-N use increased in both races. GDMT utilization, particularly ACEI/ARB, should be improved in Black and Whites individuals with HFrEF.

Income level and outcomes in patients with heart failure with universal health coverage

ObjectiveWe aimed to investigate the influence of income level on guideline-directed medical therapy (GDMT) prescription rates and prognosis of patients with heart failure (HF) following implementation of a nationwide health...

Abstract 14370: Rapidly Improving Adherence to Guideline-Directed Medical Therapies in Metropolitan Heart Failure Systems of Care

Background: The 2017 AHA/ACC/HFSA Focused Update of the 2013 ACC/AHA Guidelines for the Management of Heart Failure provided additional support for the clinical use of ACEI, ARBs or ARNIs in conjunction with Evidence-Based Beta Blockers and Aldosterone Antagonists in HFrEF, otherwise known as Guideline-Directed Medical Therapy (GDMT). Although these updates clarified the benefits of GDMT to patient outcomes, low rates of adherence at the provider level for both hospitalized and ambulatory patients continue to be seen. Methods: With the objective of rapidly improving GDMT utilization, as well as improving patient outcomes, the American Heart Association initiated a multidisciplinary collaborative in three metropolitan markets - Chicago, Milwaukee, and St. Louis. Utilizing Get With The Guidelines®-Heart Failure (GWTG-HF), 40 hospitals tracked patients discharged with a primary diagnosis of heart failure and entered data from their inpatient and 30-days post-acute record. An initiative benchmark group was created to track progress and revisions were made to the post-acute care form. Hospitals were provided targeted consultation using hospital-specific data compared to regional and initiative benchmarks. The initiative provided exclusive professional education, including webinars, collaboration meetings, and best-practice recommendations. Results: Between January 1, 2019 and December 31, 2019, 10,532 patients with a primary diagnosis of heart failure, were entered into GWTG-HF from the 40 initiative hospitals, in which 3807 had an EF of &lt;40%. A comparison from Q1 to Q4, 2019 of the mean adherence for GDMT was performed at discharge and yielded the following results: ACEI/ARB or ARNi from 89.3% to 91.6%, Evidenced-Based Beta Blockers from 90.3% to 94.2% and Aldosterone Antagonist from 53.6% to 64.7%; At 30-Days the mean adherence for Q1 and Q4 were calculated as follows: ACEI/ARB or ARNi from 60.4% to 72.9% and Aldosterone Antagonist from 28.2% to 55.3%. Evidence-Based Beta Blocker was only captured for Q3 and Q4, 2019 and the mean adherence improved from 70.3% to 73.8%. Conclusions: The multi-city quality initiative early results show a positive correlation in improving adherence to GDMT in both the hospital and ambulatory setting.

Congestive Heart Failure Readmission and Guideline Based Therapy Rates Improvement At Safety Net Hospital Heart Health Center

Introduction The 2017 HFSA co-sponsored guidelines on heart failure (HF) focus on developing strategies to lower readmission rates and increase adherence to guideline directed medical therapy (GDMT), specifically beta blockers (BB), ACE inhibitors and Angiotensin II receptor blockers (ACEi/ARB), spironolactone, Bidil or combined hydralazine/isosorbide dinitrate (Hydral/ISDN), and ARB with neprilysin inhibitor (ARNI). Patients with HF at a disproportionately elevated risk for readmission are those in median-low income, often minority populations, at public safety net hospitals. The Heart Health Center (HHC) at NYC Health + Hospitals, Kings County, the largest public hospital in Brooklyn, New York, was established in October 2017 to provide comprehensive integrated inpatient-outpatient HF care coordinating the management of patients hospitalized on the inpatient cardiology primary service and the outpatient multidisciplinary HF clinic. Hypothesis High-risk patients hospitalized at public medical centers and safety net hospitals with HF have improved rates of rehospitalization GDMT utilization when admitted to dedicated cardiology inpatient primary services and care teams. Methods Retrospective review was conducted of patients admitted with HF from November 2017 - November 2018 referred for post-discharge HHC HF clinic follow up, with readmission monitored through November 2019. Patients admitted to cardiology telemetry service (CT), the inpatient arm of the HHC, were compared to patients admitted to general medicine service (GM). Two-proportion z testing was performed for analysis for 30-day and 1-year overall, HF, and non-HF readmission. Odds ratio (OR) and confidence interval (CI) via McNemar were used for analysis of admission and discharge GDMT changes. Results CT patients (n=125) exhibited lower 30-day and 1-year overall, HF, and non-HF readmission rates than GM (n=69) patients, with 30-day overall readmission rates being significant (24% v 39.1%, p=0.04). When comparing admission and discharge medication reconciliations, CT patients had significantly increased likelihood of being discharged on all classes of GDMT, BB (OR 22.5, CI 5.9 - 191.5, p Conclusions Among HF patients at a public safety net medical center at high risk for readmission, hospitalization under a primary cardiology care team in an integrated inpatient-outpatient HF service was associated with improvement in readmission outcomes and GMT adherence. This study has important implications for strategies for safety net hospitals and medical centers serving broader populations.

Heart Failure Optimize Clinic: Improving Quality of Care In Heart Failure Patients In An Academic Medical Center

Background While heart failure (HF) is a leading cause of mortality and readmissions, only a small percentage of patients are optimized on guideline-directed medical therapy (GDMT). We developed a multidisciplinary HF clinic to optimize medications, provide education and resources and screen for medical co-morbidities in HF patients. Methods A multidisciplinary clinic composed of Advanced Practice Providers (APPs), pharmacist, nutritionists and nurses was developed and targeted patients with a 30-day HF readmission, ≥ 2 HF-related hospitalizations in last 12 months or new HF diagnosis. The OPTIMIZE clinic consisted of a total of 6 visits approximately two weeks apart seeing an APP at each visit along with pharmacy and nutrition evaluation. Echocardiographic, 6-minute walk, and health related quality of life (EQ5D) outcomes were measured at baseline and at the end of the 12 weeks. Results A total of 62 patients with heart failure with reduced ejection fraction (HFrEF) completed OPTIMIZE clinic over an average of 11.6 weeks. Patients were primarily white (62.3%) males (56.5%) with an average age of 59.1 (±15.3) years. HF etiology was primarily non-ischemic (65%) and patients had typical cardiac comorbidities - hypertension 54%, hyperlipidemia 33%, diabetes 23%, sleep apnea 15%, and chronic kidney disease 24%. Completion of OPTIMIZE clinic resulted in significant improvements in 6-minute walk distance, left ventricular ejection fraction (LVEF), and patient reported quality of life measures as assessed by the EQ5D along with significant reductions in brain natriuretic peptide (BNP) and left ventricular internal diameter in diastole (LVIDd) (Figure 1a). We also saw improved utilization of GDMT with completion of the OPTIMIZE clinic (Figure 1b). During the course of the clinic, only 7 (11%) patients were admitted for CHF exacerbation and 44 referrals were made to various other cardiology or internal medicine subspecialities, the most common being sleep clinic (14 referrals). A total of 13 (21%) patients had enough improvement in LVEF on GDMT as a result of this clinic that they no longer met criteria for implantable cardioverter defibrillator implantation. Conclusion Successful implementation of a multidisciplinary HF optimization clinic can help improve GDMT utilization, HF education, comorbidity recognition, and markers of HF severity. An OPTIMIZE clinic model can be considered in other centers as a way to increase GDMT optimization and improve clinical and functional markers of HF.

Abstract 218: Improving Guideline-Directed Medical Therapy Utilization for Heart Failure With Reduced Ejection Fraction Within a Veteran's Affairs Health System

Despite a robust evidence base and well-established clinical guidelines for patients with HFrEF, a significant number of patients with this disease are not currently prescribed ACEI/ARB/ARNI and beta-blocker therapies at or near target doses proven to reduce the risk of cardiovascular events and mortality in randomized clinical trials. Within the VA Palo Alto Health System we found that the minority of patients with HFrEF prescribed these therapies were receiving ACEI/ARB/ARNI (45.2%: 410 of 908) and beta-blockers (45.4%: 458 of 1008) at ≥50% of target doses. Limited general medicine and cardiology appointment availability as well as clinical inertia were identified as root causes of suboptimal dosing of guideline-directed medical therapy (GDMT). We addressed these with implementation of a pharmacist driven Heart Failure Medication Titration Clinic through a shared practice agreement with general medicine physicians, initially at one clinical site with 190 total HFrEF patients. An academic detailing clinical dashboard including medication prescribing and LV ejection fraction data (obtained via natural language processing of imaging reports) is utilized by the on-site clinical pharmacist to identify actionable HFrEF patients on suboptimal GDMT. If felt appropriate for escalation of therapy, a patient’s primary care physician or cardiologist approves a referral to the clinic. The pharmacist then conducts regular clinic or telephone visits (typically every two weeks) with the patient to assess tolerance of therapy and eligibility for further dose escalation per an established titration algorithm that integrates recent symptoms, vital signs, and lab values. In three months, patients referred to the Heart Failure Medication Titration Clinic have had their average ACE/ARB/ARNI dose escalated from 21.9% to 42.7% of target dose and their average beta-blocker dose escalated from 56.3% to 81.3% of target dose. No adverse medication events or hospitalizations have occurred. There has been a corresponding increase in the overall percentage of this clinical site’s HFrEF patients on ACEI/ARB/ARNI (36.4% to 43.7%: 55 of 126) and beta-blockers (39.4% to 43.0%: 55 of 128) that are receiving ≥50% of target dose therapy. These results suggest that clinical pharmacists can play a vital role in identifying and treating patients that are on suboptimal treatment for HFrEF via utilization of an academic detailing dashboard and pharmacist led medication titration clinics. Limitations of this quality improvement initiative include short duration of follow-up to date and performance of these interventions within an integrated health care system, which may not be generalizable to other health care delivery models. Next steps include addition of mineralocorticoid antagonist therapy to our titration algorithm and scaling these interventions to additional clinical sites within our health system.

Implantable Cardioverter Defibrillator Use in Males with Duchenne Muscular Dystrophy and Severe Left Ventricular Dysfunction.

Duchenne muscular dystrophy (DMD) is characterized by myocardial fibrosis and left ventricular (LV) dysfunction. Implantable cardioverter defibrillator (ICD) use has not been characterized in this population but is considered for symptomatic patients with severe LV dysfunction (SLVD) receiving guideline-directed medical therapy (GDMT). We evaluated ICD utilization and efficacy in patients with DMD. Retrospective cohort study of DMD patients from 17 centers across North America between January 2, 2005 and December 31, 2015. ICD use and its effect on survival were evaluated in patients with SLVD defined as ejection fraction (EF) < 35% and/ or shortening fraction (SF) < 16% on final echocardiogram. SLVD was present in 57/436 (13.1%) patients, of which 12 (21.1%) died during the study period. Of these 12, (mean EF 20.9 ± 6.2% and SF 13.7 ± 7.2%), 8 received GDMT, 5 received steroids, and none received an ICD. ICDs were placed in 9/57 (15.8%) patients with SLVD (mean EF 31.2 ± 8.5% and SF 10.3 ± 4.9%) at a mean age of 20.4 ± 6.3years; 8/9 received GDMT, 7 received steroids, and all were alive at study end; mean ICD duration was 36.1 ± 26.2months. Nine ICDs were implanted at six different institutions, associated with two appropriate shocks for ventricular tachycardia in two patients, no inappropriate shocks, and one lead fracture. ICD use may be associated with improved survival and minimal complications in DMD cardiomyopathy with SLVD. However, inconsistent GDMT utilization may be a significant confounder. Future studies should define optimal indications for ICD implantation in patients with DMD cardiomyopathy.

Sex- and age-related differences in the management and outcomes of chronic heart failure: an analysis of patients from the ESC HFA EORP Heart Failure Long-Term Registry.

This study aimed to assess age- and sex-related differences in management and 1-year risk for all-cause mortality and hospitalization in chronic heart failure (HF) patients. Of 16 354 patients included in the European Society of Cardiology Heart Failure Long-Term Registry, 9428 chronic HF patients were analysed [median age: 66 years; 28.5% women; mean left ventricular ejection fraction (LVEF) 37%]. Rates of use of guideline-directed medical therapy (GDMT) were high (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists: 85.7%, 88.7% and 58.8%, respectively). Crude GDMT utilization rates were lower in women than in men (all differences: P≤ 0.001), and GDMT use became lower with ageing in both sexes, at baseline and at 1-year follow-up. Sex was not an independent predictor of GDMT prescription; however, age >75 years was a significant predictor of GDMT underutilization. Rates of all-cause mortality were lower in women than in men (7.1% vs. 8.7%; P=0.015), as were rates of all-cause hospitalization (21.9% vs. 27.3%; P<0.001) and there were no differences in causes of death. All-cause mortality and all-cause hospitalization increased with greater age in both sexes. Sex was not an independent predictor of 1-year all-cause mortality (restricted to patients with LVEF ≤45%). Mortality risk was significantly lower in patients of younger age, compared to patients aged >75 years. There was a decline in GDMT use with advanced age in both sexes. Sex was not an independent predictor of GDMT or adverse outcomes. However, age >75 years independently predicted lower GDMT use and higher all-cause mortality in patients with LVEF ≤45%.

Use of the guidelines directed medical therapy after coronary artery bypass graft surgery in Saudi Arabia

Background: incidence of cardiovascular diseases in Saudi Arabia is growing and more patients are expected to have cardiac revascularization surgery. Optimal pharmacotherapy management with Guideline Directed Medical Therapy (GDMT) post coronary artery bypass grafting (CABG) plays an important role in the prevention of adverse cardiovascular outcomes. The objective of this study was to assess the utilization of GDMT for secondary prevention in CABG patients and determine whether specific patients' characteristics can influence GDMT utilization. Method: A retrospective chart review of patients discharged from the hospital after CABG surgery from April 2015 to April 2016. The primary outcome was the utilization of secondary prevention GDMT after CABG surgery - aspirin, B-blockers, statin and angiotensin-converting enzyme inhibitors (ACEI) (or angiotensin receptor blockers (ARB) in ACEI-intolerant patients). The proportions of eligible and ideal patients who received treatment were calculated, and mixed-effects logistic regression was used to estimate odds ratios (OR) for the association of age, gender or patient nationality with the use of GDMT. Results: A total number of 119 patients included in the analysis. The median age of the cohort was 57.3±11years, and 83% were male (83.2%). Nearly 69.7% of patients had diabetes, and 82% had a previous diagnosis of hypertension. Nearly 91% received aspirin therapy and the rate was lower for B-blocker and statin. The rate of GDMT utilization did not change with the change in patient’s age, gender or nationality. Conclusion: Despite adjustments for contraindications to GDMT, the rate of GDMT utilization was suboptimal.