Contemporary Drug Treatment of Chronic Heart Failure With Reduced Ejection Fraction: The CHECK-HF Registry

Abstract

Objectives: This study investigated adherence to drug therapy guidelines in heart failure (HF) with reduced left-ventricular ejection fraction (LVEF) of <40% (heart failure with reduced ejection fraction [HFrEF]), in which evidence-based treatment has been established.

Background: Despite previous surveys of HF, important uncertainties remain regarding guideline adherence in a representative real-world population.

Methods: A cross-sectional registry in 34 Dutch HF outpatient clinics that included 10,910 patients with the diagnosis of HF was examined. Of that number, 8,360 patients had LVEF <50% (72 ± 12 years of age; 64% male) and were divided into HFrEF (n = 5,701), HF with mid-range LVEF (HFmrEF) with LVEF 40% to 49% (n = 1,574), and those with semiquantitatively measured LVEF but <50% (n = 1,085).

Results: In the HFrEF group, 81% of the patients were treated with loop diuretics, 84% with renin-angiotensin-system (RAS) inhibitors, 86% with β-blockers, 56% with mineralocorticoid-receptor antagonists (MRA), and 5% with I_f-channel inhibition. Differences in medication use were minor among the 3 groups but were significant among centers. Inability to tolerate the medications was recorded in 9.4% patients taking RAS inhibitors, 3.3% taking β-blockers, and 5.4% taking MRAs. Median loop diuretic dose was 40 mg of furosemide equivalent, RAS inhibitor dose 50% of target, β-blocker dose 25% of target, and MRA dose 12.5 mg of spironolactone equivalent. Elderly patients were treated predominantly with diuretics and less often with RAS inhibitors, β-blockers, and MRAs.

Conclusions: This large contemporary HF registry showed a relatively high use of evidence-based treatment, particularly in younger patients. However, the average dose of evidence-based medication was still lower than recommended by guidelines. Furthermore, the more recently introduced I_f-channel inhibition has hardly been adopted. There is ample room for improvement of HFrEF therapy, even more than 25 years after convincing evidence that HFrEF treatment leads to better outcome.

Keywords: HFrEF; guideline adherence; heart failure; reduced ejection fraction; registry; treatment.