Key result
Higher GDMT use and uptitration are linked to ~29% lower HF hospitalization in repaired biventricular CHD.
Why the study?
Studies assessing the clinical benefits of GDMT for heart failure in adults with congenital heart disease have yielded conflicting results due to population heterogeneity and lack of standardized criteria.
Does higher baseline use and uptitration of guideline-directed medical therapy (GDMT) reduce heart failure hospitalization and mortality in adults with repaired systemic biventricular congenital heart disease and HFrEF?
Does higher baseline use and uptitration of guideline-directed medical therapy (GDMT) reduce heart failure hospitalization and mortality in adults with repaired systemic biventricular congenital heart disease and HFrEF?
Higher baseline use and uptitration of GDMT are associated with a dose-dependent reduction in HF hospitalization and mortality in adults with repaired systemic biventricular CHD and HFrEF, highlighting a significant opportunity for quality improvement as 67% of patients did not receive uptitration.
Supports GDMT uptitration in repaired systemic biventricular CHD with HFrEF; extends acquired HFrEF evidence but remains hypothesis-generating.
Results of observational studies assessing clinical benefits of guideline directed medical therapy (GDMT) for heart failure (HF) in adults with congenital heart disease (CHD) are conflicting. This is because these studies were based on a heterogenous population and lacked standardized criteria for assessing adequacy of HF therapy across studies. The current study addressed these limitations by studying the effect of GDMT (using a standardized GDMT score) in adults with repaired systemic biventricular CHD, systemic left ventricle and HF with reduced ejection fraction (HFrEF). HFrEF was defined as stage B/C HF and systemic left ventricular EF<50%. GDMT score was assessed at baseline encounter (baseline GDMT score) and 1-year follow-up. GDMT uptitration was calculated as defined as ∆GDMT (∆=delta or change in) score from baseline. Cox regression was used to assess the relationship between HF therapy (baseline and ∆GDMT score) and outcomes (HF hospitalization and mortality). Of 778 patients, baseline and ∆GDMT scores were 2 (1,3) and 0.56 (0.49,0.62), respectively. Of 778, only 258 (33%) had GDMT uptitration (∆GDMT score >0). Higher use of GDMT at baseline (adjusted HR per 1 point increase in GDMT score 0.83, 95%CI 0.74, 0.92, p<0.001), and increased use of GDMT over time (adjusted HR for 1 point increase in ∆GDMT score HR 0.71, 95%CI 0.62, 0.82, p<0.001) were associated with lower risk of HF hospitalization. Higher baseline GDMT score (adjusted HR 0.87, 95%CI 0.76, 0.98, p=0.01), and ∆ GDMT score (adjusted HR 0.84, 95%CI 0.72, 0.86, p=0.002) were also associated with lower mortality. GDMT use at baseline and GDMT uptitration were associated with improved outcomes and suggest a dose-dependent relationship between use of GDMT and risk of adverse outcomes. Furthermore, 67% of patients did not receive GDMT uptitration, suggesting suboptimal therapy, and opportunities for improvement.
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Ellabbad et al. (2026) studied this question. Higher baseline GDMT and GDMT uptitration reduced heart failure hospitalization risk (HR 0.83 and 0.71) and mortality (HR 0.87 and 0.84) in repaired systemic biventricular CHD adults.
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