Frailty in older adults with HFrEF was associated with a lower likelihood of initiating ARNI therapy (OR 0.87; 95% CI 0.81-0.94).
Cohort (n=180,386)
Does frailty affect the uptake of ARNI and GDMT, and does GDMT reduce death or heart failure hospitalization in older adults with HFrEF?
Frail older adults with HFrEF are less likely to receive ARNI and GDMT, despite GDMT being associated with reduced death or heart failure hospitalization regardless of frailty status.
Effect estimate: OR 0.87 (95% CI 0.81-0.94)
BACKGROUND: Frail older adults may be less likely to receive guideline-directed medical therapy (GDMT)-renin-angiotensin blockers, beta-blockers, and mineralocorticoid receptor antagonists-for heart failure with reduced ejection fraction (HFrEF). We aimed to examine the uptake of angiotensin receptor neprilysin inhibitor (ARNI) and GDMT in frail older adults with HFrEF. METHODS: Using 2015-2019 Medicare data, we estimated the proportion of beneficiaries with HFrEF receiving ARNI and GDMT each year by frailty status, defined by a claims-based frailty index. Logistic regression was used to identify clinical characteristics associated with ARNI initiation. Cox proportional hazards regression was used to examine the association of GDMT use in 2015 and death or heart failure hospitalization in 2016-2019. RESULTS: Among 147,506-180,386 beneficiaries with HFrEF (mean age: 77 years; 27% women; 42.6-49.1% frail) in 2015-2019, the proportion of patients receiving ARNI increased in both non-frail (0.4%-16.4%) and frail (0.3%-13.7%) patients (p for yearly-trend-by-frailty = 0.970). Among those not receiving a renin-angiotensin system blocker, patients with age ≥ 85 years (odds ratio 95% CI, 0.89 0.80-0.99), dementia (0.88 0.81-0.96), and frailty (0.87 0.81-0.94) were less likely to initiate ARNI. The proportion of patients receiving all 3 GDMT classes increased in non-frail patients (22.0%-27.0%) but changed minimally in frail patients (19.6%-21.8%). Regardless of frailty status, treatment with at least 1 class of GDMT was associated with lower death or heart failure hospitalization than no GDMT medications (hazard ratio 95% CI, 0.94 0.91-0.97, 0.92 0.89-0.94, 0.94 0.91-0.97 for 1, 2, and 3 classes, respectively). CONCLUSIONS: Our results suggest an evidence-practice gap in the use of ARNI and GDMT in Medicare beneficiaries with HFrEF, particularly those with frailty. Efforts to narrow this gap are needed to reduce the burden of HFrEF in older adults.
Lee et al. (Thu,) conducted a cohort in heart failure with reduced ejection fraction (HFrEF) (n=180,386). angiotensin receptor neprilysin inhibitor (ARNI) and GDMT vs. non-frail patients / no GDMT was evaluated on ARNI initiation among those not receiving a renin-angiotensin system blocker (OR 0.87, 95% CI 0.81-0.94). Frailty in older adults with HFrEF was associated with a lower likelihood of initiating ARNI therapy (OR 0.87; 95% CI 0.81-0.94).