Contemporary Guideline-Directed Medical Therapy and Outpatient Worsening Heart Failure Events in Hospitalized Patients With Heart Failure - Preliminary Observational Study on Utilizing Predischarge Period for Optimizing Medications in Hospitalized Patients With Heart Failure (PRE-UPFRONT-HF)

Abstract

Background: Adherence to contemporary guideline-directed medical therapy (GDMT) and its association with incident outpatient worsening heart failure (WHF) events after discharge in hospitalized patients with heart failure (HF) remain unclear.

Methods and results: The PRE-UPFRONT-HF study was a retrospective multicenter observational registry of patients hospitalized for HF between June 2022 and March 2023 with a left ventricular ejection fraction <50%. Data on medications at admission, discharge, and 6 months after admission were collected. Outpatient WHF was defined as intravenous diuretic therapy and/or intensification of oral diuretics in outpatient settings (e.g., without hospitalization). Less than half the 442 patients registered were on all 4 GDMT medications (β-blockers, renin-angiotensin-aldosterone system inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors) at discharge and 6 months after admission. Better GDMT implementation, defined by a simple GDMT score above the median, was significantly associated with a lower incidence of composite outcomes of death, HF hospitalization, and WHF (P<0.001), as well as outpatient WHF events alone (P=0.035), which remained significant even after adjusting for covariates. In addition, outpatient WHF was associated with subsequent worse prognoses, including mortality (hazard ratio 6.52; P<0.001).

Conclusions: GDMT implementation during hospitalization for HF is suboptimal, even in the contemporary era. Patients with better GDMT implementation at discharge had a lower incidence of outpatient WHF, which was associated with subsequent mortality.

Keywords: Guideline-directed medical therapy; Heart failure with mildly reduced ejection fraction (HFmrEF); Heart failure with reduced ejection fraction (HFrEF); Worsening heart failure.