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. 2021 Jan;9(1):28-38.
doi: 10.1016/j.jchf.2020.08.017. Epub 2020 Dec 9.

Heart Failure Hospitalization and Guideline-Directed Prescribing Patterns Among Heart Failure With Reduced Ejection Fraction Patients

Pratyaksh K Srivastava  1 , Adam D DeVore  2 , Anne S Hellkamp  3 , Laine Thomas  3 , Nancy M Albert  4 , Javed Butler  5 , J Herbert Patterson  6 , John A Spertus  7 , Fredonia B Williams  8 , Carol I Duffy  9 , Adrian F Hernandez  2 , Gregg C Fonarow  10
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Free article

Heart Failure Hospitalization and Guideline-Directed Prescribing Patterns Among Heart Failure With Reduced Ejection Fraction Patients

Pratyaksh K Srivastava et al. JACC Heart Fail. 2021 Jan.
Free article

Abstract

Objectives: The authors sought to evaluate the association of heart failure hospitalization (HFH) with guideline-directed medical therapy (GDMT) prescribing patterns among patients with heart failure with reduced ejection fraction (HFrEF).

Background: HFH represents an important opportunity to titrate GDMT among patients with HFrEF.

Methods: The CHAMP-HF (Change the Management of Patients With Heart Failure) registry is a prospective registry of adults with HFrEF (ejection fraction ≤40%). Using data from the CHAMP-HF registry (N = 4,365), adjusted time-to-event models were created to study the association of HFH with GDMT prescribing patterns.

Results: HFH (compared with no HFH) was positively associated with initiation of angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), angiotensin receptor-neprilysin inhibitor, beta-blocker, and mineralocorticoid receptor antagonist (MRA). HFH positively associated with dose escalation of ACE inhibitor/ARB (probability ratio: 1.71, 95% confidence interval [CI]: 1.36 to 2.16) and MRA (probability ratio: 8.71, 95% CI: 4.19 to 18.10). In those on prior therapy, HFH was associated with discontinuation and de-escalation of all classes of GDMT. ACE inhibitor/ARB, angiotensin receptor-neprilysin inhibitor, beta-blocker, and MRA de-escalation/discontinuation after HFH was associated with increased risk of all-cause mortality with hazard ratios of 3.82 (95% CI: 2.42 to 6.03), 4.76 (95% CI: 2.06 to 11.03), 2.94 (95% CI: 2.04 to 4.25), and 4.81 (95% CI: 2.61 to 8.87), respectively.

Conclusions: HFH positively associated with changes in GDMT, including initiation, dose escalation, discontinuation, and dose de-escalation. De-escalation/discontinuation of GDMT after HFH associated with increased risk of all-cause mortality. Educational endeavors are needed to ensure GDMT is not inappropriately held in the setting of HFH. For those in whom GDMT must be held/decreased, improvement tools at discharge and post-discharge titration clinics may help ensure lifesaving GDMT regimens remain optimized.

Keywords: guideline-directed medical therapy; heart failure; hospitalization.

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Conflict of interest statement

Author Disclosures The CHAMP HF registry and this study were funded by Novartis. Dr. DeVore has received research funding from the American Heart Association, Amgen, Bayer, Intra-Cellular Therapies, Luitpold Pharmaceuticals, the National Heart, Lung, and Blood Institute, Novartis, and PCORI; and has provided consulting services for Amgen, AstraZeneca, Bayer, InnaMed, Mardil Medical, Novartis, Procyrion, scPharmaceuticals, and Zoll. Dr. Albert has been a consultant for Amgen, AstraZeneca, Boston Scientific, and Novartis. Dr. Spertus has been a consultant for Novartis, Amgen, Bayer, Janssen, United Healthcare, and AstraZeneca; has served on the board of directors for Blue Cross Blue Shield of Kansas City; and has equity in Health Outcomes Sciences and copyright ownership of KCCQ, SAQ and PAQ. Dr. Duffy is an employee of Novartis. Dr. Hernandez has received research funding from AstraZeneca, American Regent, Novartis, and Verily; and has provided consulting services for Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Boston Scientific, Merck, and Novartis. Dr. Fonarow has been a consultant for Abbott, Amgen, CHF Solutions, Janssen, Medtronic, Merck, and Novartis. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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