Use Of Guideline-directed Medical Therapy Research Articles

Association of Sex and Trends in Guideline-directed Medical Therapy Use Among Patients Undergoing Intervention for Infrainguinal Peripheral Artery Disease in the Vascular Quality Initiative, 2010-2023

Association of Sex and Trends in Guideline-directed Medical Therapy Use Among Patients Undergoing Intervention for Infrainguinal Peripheral Artery Disease in the Vascular Quality Initiative, 2010-2023

Contemporary guideline-directed medical therapy in de novo, chronic, and worsening heart failure patients: First data from the TITRATE-HF study.

Despite clear guideline recommendations for initiating four drug classes in all patients with heart failure (HF) with reduced ejection fraction (HFrEF) and the availability of rapid titration schemes, information on real-world implementation lags behind. Closely following the 2021 ESC HF guidelines and 2023 focused update, the TITRATE-HF study started to prospectively investigate the use, sequencing, and titration of guideline-directed medical therapy (GDMT) in HF patients, including the identification of implementation barriers. TITRATE-HF is an ongoing long-term HF registry conducted in the Netherlands. Overall, 4288 patients from 48 hospitals were included. Among these patients, 1732 presented with de novo, 2240 with chronic, and 316 with worsening HF. The median age was 71 years (interquartile range [IQR] 63-78), 29% were female, and median ejection fraction was 35% (IQR 25-40). In total, 44% of chronic and worsening HFrEF patients were prescribed quadruple therapy. However, only 1% of HFrEF patients achieved target dose for all drug classes. In addition, quadruple therapy was more often prescribed to patients treated in a dedicated HF outpatient clinic as compared to a general cardiology outpatient clinic. In each GDMT drug class, 19% to 36% of non-use in HFrEF patients was related to side-effects, intolerances, or contraindications. In the de novo HF cohort, 49% of patients already used one or more GDMT drug classes for other indications than HF. This first analysis of the TITRATE-HF study reports relatively high use of GDMT in a contemporary HF cohort, while still showing room for improvement regarding quadruple therapy. Importantly, the use and dose of GDMT were suboptimal, with the reasons often remaining unclear. This underscores the urgency for further optimization of GDMT and implementation strategies within HF management.

Management of Heart Failure in a Resource-Limited Setting: Expert Opinion from India.

Heart failure poses a global health challenge affecting millions of individuals, and access to guideline-directed medical therapy is often limited. This limitation is frequently attributed to factors such as drug availability, slow adoption, clinical inertia, and delayed diagnosis. Despite international recommendations promoting the use of guideline-directed medical therapy for heart failure management, personalized approaches are essential in settings with resource constraints. In India, crucial treatments like angiotensin II receptor blocker neprilysin inhibitors and sodium-glucose co-transporter 2 inhibitors are not fully utilized despite their established safety and efficacy. To address this issue, an expert consensus involving 150 specialists, including cardiologists, nephrologists, and endocrinologists, was convened. They deliberated on patient profiles, monitoring, and adverse side effects and provided tailored recommendations for guideline-directed medical therapy in heart failure management. Stressing the significance of early initiation of guideline-directed medical therapy in patientswith heart failure, especially with sodium-glucose co-transporter 2 inhibitors, the consensus also explored innovative therapies like vericiguat. To improve heart failure outcomes in resource-limited settings, the experts proposed several measures, including enhanced patient education, cardiac rehabilitation, improved drug access, and reforms in healthcare policies.

Telephone-Based Guideline-Directed Medical Therapy Optimization in Navajo Nation

Underutilization of guideline-directed medical therapy for heart failure with reduced ejection fraction is a major cause of poor outcomes. For many American Indian patients receiving care through the Indian Health Service, access to care, especially cardiology care, is limited, contributing to poor uptake of recommended therapy. To examine whether a telehealth model in which guideline-directed medical therapy is initiated and titrated over the phone with remote telemonitoring using a home blood pressure cuff improves guideline-directed medical therapy use (eg, drug classes and dosage) in patients with heart failure with reduced ejection fraction in Navajo Nation. The Heart Failure Optimization at Home to Improve Outcomes (Hózhó) randomized clinical trial was a stepped-wedge, pragmatic comparative effectiveness trial conducted from February to August 2023. Patients 18 years and older with a diagnosis of heart failure with reduced ejection fraction receiving care at 2 Indian Health Service facilities in rural Navajo Nation (defined as having primary care physician with 1 clinical visit and 1 prescription filled in the last 12 months) were enrolled. Patients were randomized to the telehealth care model or usual care in a stepped-wedge fashion, with 5 time points (30-day intervals) until all patients crossed over into the intervention. Data analyses were completed in January 2024. A phone-based telehealth model in which guideline-directed medical therapy is initiated and titrated at home, using remote telemonitoring with a home blood pressure cuff. The primary outcome was an increase in the number of guideline-directed classes of drugs filled from the pharmacy at 30 days postrandomization. Of 103 enrolled American Indian patients, 42 (40.8%) were female, and the median (IQR) age was 65 (53-77) years. The median (IQR) left ventricular ejection fraction was 32% (24%-36%). The primary outcome occurred significantly more in the intervention group (66.2% vs 13.1%), thus increasing uptake of guideline-directed classes of drugs by 53% (odds ratio, 12.99; 95% CI, 6.87-24.53; P < .001). The number of patients needed to receive the telehealth intervention to result in an increase of guideline-directed drug classes was 1.88. In this heart failure trial in Navajo Nation, a telephone-based strategy of remote initiation and titration for outpatients with heart failure with reduced ejection fraction led to improved rates of guideline-directed medical therapy at 30 days compared with usual care. This low-cost strategy could be expanded to other rural settings where access to care is limited. ClinicalTrials.gov Identifier: NCT05792085.

(830) - Guideline-Directed Medical Therapy Use in a Contemporary Multicenter Cohort of Hm3 LVAD Recipients

(830) - Guideline-Directed Medical Therapy Use in a Contemporary Multicenter Cohort of Hm3 LVAD Recipients

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

Sex Differences in Revascularization, Treatment Goals, and Outcomes of Patients With Chronic Coronary Disease: Insights From the ISCHEMIA Trial.

Women with chronic coronary disease are generally older than men and have more comorbidities but less atherosclerosis. We explored sex differences in revascularization, guideline-directed medical therapy, and outcomes among patients with chronic coronary disease with ischemia on stress testing, with and without invasive management. The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial randomized patients with moderate or severe ischemia to invasive management with angiography, revascularization, and guideline-directed medical therapy, or initial conservative management with guideline-directed medical therapy alone. We evaluated the primary outcome (cardiovascular death, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest) and other end points, by sex, in 1168 (22.6%) women and 4011 (77.4%) men. Invasive group catheterization rates were similar, with less revascularization among women (73.4% of invasive-assigned women revascularized versus 81.2% of invasive-assigned men; P<0.001). Women had less coronary artery disease: multivessel in 60.0% of invasive-assigned women and 74.8% of invasive-assigned men, and no ≥50% stenosis in 12.3% versus 4.5% (P<0.001). In the conservative group, 4-year catheterization rates were 26.3% of women versus 25.6% of men (P=0.72). Guideline-directed medical therapy use was lower among women with fewer risk factor goals attained. There were no sex differences in the primary outcome (adjusted hazard ratio [HR] for women versus men, 0.93 [95% CI, 0.77-1.13]; P=0.47) or the major secondary outcome of cardiovascular death/myocardial infarction (adjusted HR, 0.93 [95% CI, 0.76-1.14]; P=0.49), with no significant sex-by-treatment-group interactions. Women had less extensive coronary artery disease and, therefore, lower revascularization rates in the invasive group. Despite lower risk factor goal attainment, women with chronic coronary disease experienced similar risk-adjusted outcomes to men in the ISCHEMIA trial. URL: http://wwwclinicaltrials.gov. Unique identifier: NCT01471522.

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.

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.

Impact of Multidisciplinary Heart Failure Clinic on Guideline-Directed Medical Therapy and Clinical Outcomes.

Heart failure (HF) is associated with recurrent hospital admissions and high mortality. Guideline-directed medical therapy has been shown to improve prognosis for patients who have HF with reduced ejection fraction (HFrEF). Despite the proven benefits of guideline-directed medical therapy, its utilization is less than optimal among patients with HF in Malaysia. To determine the impact of a multidisciplinary team HF (MDT-HF) clinic on the use of guideline-directed medical therapy and patients' clinical outcomes at 1 year. This retrospective study was conducted in a single cardiac centre in Malaysia. Patients with HFrEF who were enrolled in the MDT-HF clinic between November 2017 and June 2020 were compared with a matched control group who received the standard of care. Data were retrieved from the hospital electronic system and were analyzed using statistical software. A total of 54 patients were included in each group. Patients enrolled in the MDT-HF clinic had higher usage of renin-angiotensin system blockers (54 [100%] vs 47 [87%], p < 0.001) and higher attainment of the target dose for these agents (35 [65%] vs 5 [9%], p < 0.001). At 1 year, the mean left ventricular ejection fraction (LVEF) was significantly greater in the MDT-HF group (35.7% [standard deviation 12.3%] vs 26.2% [standard deviation 8.7%], p < 0.001), and care in the MDT-HF clinic was significantly associated with better functional class, with a lower proportion of patients categorized as having New York Heart Association class III HF at 1 year (1 [2%] vs 14 [26%], p = 0.001). Patients in the MDT-HF group also had a significantly lower rate of readmission for HF (4 [7%] vs 32 [59%], p < 0.001). Patients who received care in the MDT-HF clinic had better use of guideline-directed medical therapy, greater improvement in LVEF, and a lower rate of readmission for HF at 1 year relative to patients who received the standard of care.

The Impact of Specialised Heart Failure Outpatient Care on the Long-Term Application of Guideline-Directed Medical Therapy and on Prognosis in Heart Failure with Reduced Ejection Fraction.

(1) Background: Besides the use of guideline-directed medical therapy (GDMT), multidisciplinary heart failure (HF) outpatient care (HFOC) is of strategic importance in HFrEF. (2) Methods: Data from 257 hospitalised HFrEF patients between 2019 and 2021 were retrospectively analysed. Application and target doses of GDMT were compared between HFOC and non-HFOC patients at discharge and at 1 year. 1-year all-cause mortality (ACM) and rehospitalisation (ACH) rates were compared using the Cox proportional hazard model. The effect of HFOC on GDMT and on prognosis after propensity score matching (PSM) of 168 patients and the independent predictors of 1-year ACM and ACH were also evaluated. (3) Results: At 1 year, the application of RASi, MRA and triple therapy (TT: RASi + βB + MRA) was higher (p < 0.05) in the HFOC group, as was the proportion of target doses of ARNI, βB, MRA and TT. After PSM, the composite of 1-year ACM or ACH was more favourable with HFOC (propensity-adjusted HR = 0.625, 95% CI = 0.401-0.974, p = 0.038). Independent predictors of 1-year ACM were age, systolic blood pressure, application of TT and HFOC, while 1-year ACH was influenced by the application of TT. (4) Conclusions: HFOC may positively impact GDMT use and prognosis in HFrEF even within the first year of its initiation.

Real-world evaluation of care for type 2 diabetes in Malaysia: A cross-sectional analysis of the treatment adherence to guideline evaluation in type 2 diabetes (TARGET-T2D) study.

Given a lack of data on diabetes care performance in Malaysia, we conducted a cross-sectional study to understand the clinical characteristics, control of cardiometabolic risk factors, and patterns of use of guideline-directed medical therapy (GDMT) among patients with type 2 diabetes (T2D), who were managed at publicly-funded hospitals between December 2021 and June 2022. Patients aged ≥18 years with T2D from eight publicly-funded hospitals in the Greater Kuala Lumpur region, who had ≥2 outpatient visits within the preceding year and irrespective of treatment regimen, were eligible. The primary outcome was ≥2 treatment target attainment (defined as either HbA1c <7.0%, blood pressure [BP] <130/80 mmHg, or low-density lipoprotein cholesterol [LDL-C] <1.8 mmol/L). The secondary outcomes were the individual treatment target, a combination of all three treatment targets, and patterns of GDMT use. To assess for potential heterogeneity of study findings, all outcomes were stratified according to prespecified baseline characteristics namely 1) history of atherosclerotic cardiovascular disease (ASCVD; yes/no) and 2) clinic type (Diabetes specialist versus General medicine). Among 5094 patients (mean±SD age 59.0±13.2 years; T2D duration 14.8±9.2 years; HbA1c 8.2±1.9% (66±21 mmol/mol); BMI 29.6±6.2 kg/m2; 45.6% men), 99% were at high/very high cardiorenal risk. Attainment of ≥2 treatment targets was at 18%, being higher in General medicine than in Diabetes specialist clinics (20.8% versus 17.5%; p = 0.039). The overall statin coverage was 90%. More patients with prior ASCVD attained LDL-C <1.4 mmol/L than those without (13.5% versus 8.4%; p<0.001). Use of sodium-glucose cotransporter-2 (SGLT2) inhibitors (13.2% versus 43.2%), glucagon-like peptide-1 receptor agonists (GLP1-RAs) (1.0% versus 6.2%), and insulin (27.7% versus 58.1%) were lower in General medicine than in Diabetes specialist clinics. Among high-risk patients with T2D, treatment target attainment and use of GDMT were suboptimal.

Evaluation of Guideline-Directed Medical Therapy for Outpatients Living with Heart Failure with Reduced Ejection Fraction.

Pharmacotherapy is the cornerstone of treatment for heart failure with reduced ejection fraction (HFrEF). The Canadian Cardiovascular Society and Canadian Heart Failure Society have defined guideline-directed medical therapy (GDMT) as 4 foundational medications. Despite strong recommendations for use of GDMT in HFrEF, current practice alignment with guidelines is unknown. The primary objectives were to determine the proportion of patients for whom optimized GDMT for HFrEF was prescribed, to describe the doses of foundational medications achieved, and to describe any documented rationale limiting the optimization of GDMT. The secondary objectives were to describe documented pharmacist activities outside of scheduled multidisciplinary appointments at the heart function clinic (HFC) and to describe heart failure-related hospital encounters in 2021. A retrospective cohort study using medical records of patients with HFrEF who were receiving treatment at the Regina HFC as of December 31, 2021, was conducted. Of the 129 patients included in the study, 61 (47.3%) were prescribed optimized GDMT. Specifically, within the individual foundational medication classes, 82.2% (106/129), 80.6% (104/129), 79.1% (102/129), and 74.4% (96/129) of patients received optimized therapy with a renin-angiotensin system inhibitor, mineralocorticoid receptor antagonist, β-blocker, and sodium-glucose cotransporter 2 inhibitor, respectively. Documented rationale was not available in 35.8% (38/106) of instances of suboptimal utilization of GDMT and in 41.7% (60/144) of instances of suboptimal dosing of GDMT. The most common documented rationale for suboptimal utilization was intolerance to the medication (33.0% [35/106]), and the most common rationale for suboptimal dosing was intolerance to dose increases (57.6% [83/144]). Pharmacists documented a total of 553 patient care activities for 58.9% (76/129) of the patients, outside scheduled multidisciplinary appointments in the HFC. Sixteen patients (12.4%) had heart failure-related hospital encounters a total of 31 times in 2021. Although many patients were receiving the benefits of multidisciplinary care at the Regina HFC, there remained a treatment gap in the use of GDMT for HFrEF. These findings will be used to inform strategies to improve clinic processes, including efficient identification of patients requiring optimization of GDMT, who would benefit the most from multidisciplinary care.

Guideline-directed medical therapy in severe heart failure with reduced ejection fraction: An analysis from the HELP-HF registry.

Persistent symptoms despite guideline-directed medical therapy (GDMT) and poor tolerance of GDMT are hallmarks of patients with advanced heart failure (HF) with reduced ejection fraction (HFrEF). However, real-world data on GDMT use, dose, and prognostic implications are lacking. We included 699 consecutive patients with HFrEF and at least one 'I NEED HELP' marker for advanced HF enrolled in a multicentre registry. Beta-blockers (BB) were administered to 574 (82%) patients, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers or angiotensin receptor-neprilysin inhibitors (ACEi/ARB/ARNI) were administered to 381 (55%) patients and 416 (60%) received mineralocorticoid receptor antagonists (MRA). Overall, ≥50% of target doses were reached in 41%, 22%, and 56% of the patients on BB, ACEi/ARB/ARNI and MRA, respectively. Hypotension, bradycardia, kidney dysfunction and hyperkalaemia were the main causes of underprescription and/or underdosing, but up to a half of the patients did not receive target doses for unknown causes (51%, 41%, and 55% for BB, ACEi/ARB/ARNI and MRA, respectively). The proportions of patients receiving BB and ACEi/ARB/ARNI were lower among those fulfilling the 2018 HFA-ESC criteria for advanced HF. Treatment with BB and ACEi/ARB/ARNI were associated with a lower risk of death or HF hospitalizations (adjusted hazard ratio [HR] 0.63, 95% confidence interval [CI] 0.48-0.84, and HR 0.74, 95% CI 0.58-0.95, respectively). In a large, real-world, contemporary cohort of patients with severe HFrEF, with at least one marker for advanced HF, prescription and uptitration of GDMT remained limited. A significant proportion of patients were undertreated due to unknown reasons suggesting a potential role of clinical inertia either by the prescribing healthcare professional or by the patient. Treatment with BB and ACEi/ARB/ARNI was associated with lower mortality/morbidity.

Use of guideline-recommended heart failure drugs in high-, middle- and low-income countries: a systematic review and meta-analysis

Abstract Background/Introduction Heart failure (HF)—a major health concern affecting over 64 million individuals globally—is among the leading causes of hospitalization and death, especially in low- and middle-income countries (LMICs). Guideline-directed medical therapy (GDMT) reduces the risk of hospitalization and mortality among HF patients, however previous have suggested gaps in the adoption of HF-GDMT, with very limited data from LMICs. Purpose We performed a systematic review and meta-analysis to assess the prevalence of use of GDMT for HF with mildly reduced or reduced ejection fraction and compared it across geographic regions and country income levels. Methods We searched MEDLINE, Global health, and CINAHL from inception to October 5th, 2020, for cohort and cross-sectional studies of at least 100 patients with confirmed HF and ejection fraction ≤50%. Two reviewers independently and in duplicate conducted the study selection and data extraction. The outcome was the prevalence of GDMT use, defined as the percentage of HF patients using each class of GDMT (primarily beta blockers; renin-angiotensin-system inhibitors [RASi]; mineralocorticoid receptor antagonists [MRA], diuretics). We conducted random-effects meta-analyses to obtain summary estimates for each GDMT and performed subgroup analyses at the regional and country income levels. We used meta-regression to assess the impact on study-time with prevalence of GDMT use. We assessed risk of bias using the Joanna Briggs Institute tool for analytical cross-sectional studies. Results Overall, 334 studies comprising 1,507,849 patients were included. The majority (82%) of studies were from high-income countries (HICs), followed by upper MICs (11%), lower MICs (2%) and LICs (1%). Europe (45%) and Americas regions (33%) were the most represented, Africa (1%) the least. The overall prevalence of GDMT use was high for beta blockers (80%) and RASi (82%), and relatively low for MRA (41%). There were considerable variations across income groups and geographic regions: the use of beta blockers and RASi was the highest in HICs and in the Americas, while the use of MRA were the highest in LMICs and in Europe. After adjusting for country income level, the prevalence of use was found to increase significantly by 4% for beta blockers, 2% for MRA, and 1% for RASi every year (p&amp;lt;0.0001). The use of diuretics (76%) and digoxin (25%) decreased with time. Few studies reported the use of newer GDMT (ivabradine, sacubitril/valsartan, vasodilators), and prevalence was found to be very low. Age, sex, or presence of hypertension or ischemic heart disease did not determine the prevalence of GDMT use. Conclusion(s) Our analyses highlight that the prevalence of use of GDMT for HF has been increasing over time, but large gaps persist, particularly in LMICs. Multi-level interventions are needed to address health-system, provider, and patient-level barriers to improve the uptake of GDMT among HF patients.

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

The effect of long-term application of guideline-directed medical therapy on systolic blood pressure in hospitalized patients with heart failure with reduced ejection fraction

Abstract Background According to the current guidelines in heart failure (HF) with reduced ejection fraction (HFrEF) the implementation and titration of guideline-directed medical therapy (GDMT) is recommended. Although just symptomatic hypotension is known as a factor limiting the initiation or uptitration of GDMT, in everyday practice asymptomatic hypotension often has a negative impact on the long-term application of GDMT in HFrEF, even though patients with lower systolic blood pressure (SBP) have worse prognosis. Aim To assess the application of combined neurohormonal antagonist therapy (triple therapy [TT]: RASi[ACEi/ARB/ARNI]+βB+MRA) based on SBP during an index HF hospitalization, and to evaluate the long-term application of TT on SBP and on mortality. Patients and methods: The data of 247 consecutive HFrEF patients (male:75%, age:66[56-74]years, ischemic:46%, diabetes:40%, hypertension:63%, atrial fibrillation:46%, LVEF:25[20-30]%, eGFR:58[39-73]ml/min/1.73m2,SBP:118[102-134]mmHg) were analysed retrospectively, who had been admitted to the HF Unit of our tertiary centre due to HF in 2019-2021 and then were followed up for one year. Patients were divided into three SBP categories based on SBP measured at admission: SBP1:&amp;lt;100mmHg (n = 46), SBP2:100-120mmHg (n = 98), SBP3:&amp;gt;120mmHg (n = 103) (respectively). The applicability of TT at hospital discharge and at 1 year were assessed comparing SBP categories with Chi-square test. The changes of SBP within each category were compared with Wilcoxon test. 1-year all-cause mortality (ACM) was investigated with Kaplan-Meier method and log-rank test. Results At discharge, 77% of the patients received TT in the total cohort. Lower SBP at admission led to lower application ratio of βB (72-89-87%, p = 0.019), while RASi and MRA use was consistent across SBP categories (87-89-89%; 91-98-93%, p&amp;gt;0.05). TT application at discharge did not differ significantly among the subgroups (65-81-79%, p = 0.107). 1-year ACM was 23% in the total cohort, with significantly higher mortality rates in lower SBP groups (33-27-15%, p = 0.022). At 1 year TT application remained high; 65% in SBP1, 78% in SBP2 and 72% in SBP3 group. No differences (p&amp;gt;0.05) were seen in terms of βB (87-88-91%), RASi (81-89-84%) and MRA use (77-86-82%) in SBP groups. In the effect of GDMT, in the SBP1 and SBP2 group, SBP significantly (p&amp;lt;0.0001) rose (SBP1: from 92[85-95] to 110[95-127]mmHg, SBP2: from 111[104-117] to 124[110-133]mmHg; discharge vs. 1 year), while in the highest SBP group significant decrease was verified (from 137[129-146] to 130[118-145]mmHg, p = 0.002). Conclusions Our study results confirmed that low SBP is associated with a poor prognosis in HFrEF. Low SBP is a relevant influencing factor of GDMT initiation and long-term application, even though among these patients increase in SBP can be expected due to the use of GDMT. Our results indicate that low SBP should not make physicians be hesitant to optimize therapy in severe HFrEF.

Real world data on adopting guideline directed medical therapy post 2021 ESC HF guidelines and effect on renal function

Abstract Introduction This single-centre cohort study aims to compare the use of guideline-directed medical therapies (GDMT) before and after the 2021 ESC HF guidelines and the effect on renal function. There has been good adoption of these guidelines worldwide following the publication in 2021. We know HF patients will have less decline in renal function when GDMT is better optimised. This study aims to compare renal function on admission (adm) and discharge (dc) following acute heart failure admission. Methods Our database is composed of 460 patients with AHF admitted to our HF unit from 01/08/2020 till 31/07/2022inclusive. We divided this group into two; Group A was composed of 187 patients from August 2020 to Aug 2021(pre-ESC guidelines) and Group B included 273 patients from August 2021 to Aug 2022 (post-ESC guidelines). We compared the number of patients initiated on the 4 pillars of HF medication on admission and discharge. Both groups were analysed based on their ejection fraction (HFrEF, HFmrEF and HFpEF). Baseline parameters were were similar between the two groups. We analyzed eGFR (mL/min) on admission (adm), eGFR on discharge (dc), K+ (mmol/l) on dc and the 8 medications for HFrEF and HFmrEF. We also reviewed three medications for HFpEF. Results Group A (Aug 2020-Aug 2021): HFrEF patients had an average eGFR of 52.4 on adm and 47,0 at dc, average K+ was 4.34 on dc. HFmrEF subgroup had an average eGFR of 48.8 on adm and 45.4 at dc, average K+ was 4.23 on dc. HFpEF subgroup had an average eGFR of 51.2 on adm and 44.2 at dc, average K+ was 4.24 on dc. Group B (Aug 2021-Aug 2022): HFrEF patients had an average eGFR of 53.5 on adm and 50.7 dc, average K+ was 4.38 on dc. HFmrEF subgroup had an average eGFR of 49.4 on adm and 47.0 at dc, average K+ was 4.34 on dc. HFpEF subgroup had an average eGFR of 45.9 on adm and 41.7 at dc, average K+ was 4.35 on dc. Group A and B comparison (Table1): In Group A, HFrEF patients had a drop of eGFR of 5.4 between adm and dc. However, HFrEF patients in Group B, where they had their GDMT optimized, had an eGFR drop of only 2.8 (less by 2.6). In Group A, HFmrEF patients had an eGFR drop of 3.4 in comparison to HFmrEF patients in Group B where eGFR dropped by 2.4 (less by 1.0). In Group A, HFpEF subgroup had an eGFR drop of 7.0 versus Group B HFpEF where eGFR dropped by 4.2 only (less by 2.8). Despite better GDMT in group B, K+ was comparable to group A. Conclusions Patients with AHF managed in the HF Unit have better optimization of GDMT post 2021 HF ESC guidelines. In Group B, all patient subgroups (HFrEF; HFmrEF and HFpEF) in the year following publication of the ESC HF guidelines had a reduced decline in eGFR i.e. less worsening of renal function despite higher dose and a greater percentage of patients on the 4 pillars of GDMT. This study demonstrates that renal function of patients admitted with AHF is better preserved with optimization of GMDT during their admission.MEDICATIONS (GDMT)RENAL FUNCTION

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

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

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.