Guideline-directed medical therapy rates in heart failure patients with reduced ejection fraction in a diverse cohort

Abstract

Aims: Guideline-directed medical therapy (GDMT) is recommended for all patients with heart failure with reduced ejection fraction (HFrEF). Despite this, little data exist describing GDMT use in diverse, real-world populations including the use of vasodilators, prescribed primarily to Black populations. We sought, among a diverse population of HFrEF patients, to determine (1) GDMT use rates and target dosing by medication class and (2) predictors of GDMT use and target dosing by medication class.

Methods: We utilized electronic health records (EHRs) from Kaiser Permanente (KP) Mid-Atlantic States, a large integrated health system. Included patients had heart failure and left ventricular ejection fraction (EF) of ≤40% between 2015 and 2021. GDMT was defined by five medication classes-angiotensin-converting enzyme (ACE) inhibitors (ACEis)/angiotensin receptor blockers (ARBs)/angiotensin receptor-neprilysin inhibitors (ARNis), beta-blockers (BBs), mineralocorticoid receptor antagonists (MRAs), sodium-glucose cotransporter 2 inhibitors (SGLT2is) and vasodilators (Black patients only). Proportions of patients on GDMT and target dose rates were examined. Logistic regression determined, within each class, predictors of medication use and being at ≥80% of the target dose.

Results: A total of 3154 patients were included. Among the 93.8% on some form of GDMT, 82.8%, 81.4%, 23.5%, 3.6% and 13.4% were on ACEis/ARBs/ARNis, BBs, MRAs, SGLT2is and vasodilators (Black patients only), respectively. Among treated patients, 45.8%, 21.4%, 77.6%, 100% and 14.7% were treated at ≥80% of the target dose for ACEis/ARBs/ARNis, BBs, MRAs, SGLT2is and vasodilators, respectively. Overall, increasing age, higher EF, atrial fibrillation/flutter, chronic obstructive pulmonary disease (COPD), prior stroke and dementia were associated with decreased odds of GDMT use. Conversely, higher body mass index (BMI), Black race, higher glomerular filtration rate (GFR), recent echo and cardiac defibrillator were associated with increased odds of GDMT use. Among treated, higher BMI, higher systolic blood pressure, haemoglobin A1C ≥ 6.5% and cardiac defibrillator were associated with higher odds of being at ≥80% of the target dose.

Conclusions: Our study using real-world data from a diverse health system demonstrated gaps in GDMT use among patients with HFrEF, specifically older patients with more comorbidities.

Keywords: guideline‐directed medical therapy; heart failure with reduced ejection fraction; medication; real‐world population; target dose.

Figure 1

Patient CONSORT diagram. CHF, congestive heart failure; EF, ejection fraction; ESRD, end‐stage renal disease; KPMAS, Kaiser Permanente Mid‐Atlantic States; LVAD, left ventricular assist device.

Figure 2

(A) Rates of guideline‐directed medical treatment (GDMT) among patients with heart failure with reduced ejection fraction (HFrEF), by medication class. (B) Proportions treated to target among HFrEF patients treated with GDMT, by medication class. Patients with contraindication for each class of GDMT numbered 139, 211, 29, 0 and 0 for angiotensin‐converting enzyme (ACE)/angiotensin receptor blocker (ARB)/angiotensin receptor–neprilysin inhibitor (ARNi), beta‐blocker (BB), mineralocorticoid receptor antagonist (MRA), sodium–glucose cotransporter 2 inhibitor (SGLT2i) and vasodilators, respectively. Vasodilator estimates reported in 1730 Black patients only.

Figure 3

Factors independently associated with guideline‐directed medical treatment (GDMT) treatment (left panels) and target dosing (right panels). Number of patients excluded by model due to missing values: (A) angiotensin‐converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB)/angiotensin receptor–neprilysin inhibitor (ARNi) treated versus not treated: 99; (B) ACE/ARB/ARNi ≥ 80% target versus <80% target: 85; (C) beta‐blocker treated versus not treated: 99; (D) beta‐blocker ≥80% target versus <80% target: 84; (E) mineralocorticoid receptor antagonist (MRA) treated versus not treated: 96; (F) MRA ≥ 80% target versus <80% target: 29; (G) sodium–glucose cotransporter 2 inhibitor (SGLT2i) treated versus not treated: 98; (H) vasodilator (N = 1730) treated versus not treated: 47; and (I) vasodilator ≥80% target versus <80% target: 5. BMI, body mass index; COPD, chronic obstructive pulmonary disease; EF, ejection fraction; GFR, glomerular filtration rate; HDL, high‐density lipoprotein; HR, heart rate; LDL, low‐density lipoprotein; NDI, National Deprivation Index; PCP, primary care physician; TIA, transient ischaemic attack.