Severe kidney dysfunction (eGFR <30) in heart failure patients was associated with lower utilization of guideline-directed therapies like RASi (68% vs 94%) and MRA (35% vs 75%) compared to eGFR ≥60.
Cohort (n=1,401)
Does comorbid kidney dysfunction reduce the utilization and dose intensity of guideline-directed medical therapy in patients with heart failure?
Significant gaps in the utilization and dosing of guideline-directed heart failure therapies persist in patients with comorbid kidney dysfunction, particularly those with eGFR <30.
Abstract Aims Despite emerging evidence for new pharmacotherapies to improve outcomes in patients with heart failure (HF) and kidney dysfunction, data on contemporary HF therapy use in this population are lacking. This study evaluated contemporary longitudinal treatment patterns in patients with HF across the spectrum of kidney function and left ventricular ejection fraction (LVEF). Methods In a prospective, observational cohort of 1401 HF patients, we examined HF therapy use over 2 years and dose intensity stratified by ambulatory estimated glomerular filtration rate (eGFR ≥60, 30 to 60 and 30 mL/min/1.73 m2) and HF with reduced (HFrEF), mildly reduced (HFmrEF) and preserved (HFpEF) ejection fraction. Clinical outcomes, incidence of hyperkalaemia (serum potassium 5.5 mmol/L) and clinician-reported reasons for underutilizing HF therapies were examined. Results Median age was 68 (58 to 76) years; 29% were female; 54%, 37% and 9% had an eGFR of ≥60, 30 to 60 and 30, respectively. Among patients with eGFR ≥60, 95%, 94%, 75% and 15% were on a beta-blocker (BB), renin–angiotensin system inhibitor (RASi), mineralocorticoid receptor antagonist (MRA) and sodium glucose cotransporter-2 inhibitor, respectively. In patients with eGFR 30, corresponding baseline rates were 88%, 68%, 35% and 7%. Utilization rates were similar in patients with eGFR 30 to 60 compared with eGFR ≥60; however, fewer patients were on guideline-directed dose intensities with 44% versus 57% for RASi and 19% versus 26% for MRA. However, 90% of patients were on a BB, with similar utilization rates across HF and eGFR categories. Baseline ARNI use was 29%, 24% and 11% in eGFR ≥60, 30 to 60 and 30, respectively. Trends in HF therapy use persisted over 2 years. Among patients with eGFR 30, kidney dysfunction was the most frequently cited reason for underutilizing RASi. Patients with eGFR 60 experienced higher all-cause mortality, hospitalization and higher rates of hyperkalaemia. Conclusion Gaps in HF therapy use persist in patients with comorbid kidney dysfunction. Targeted strategies to implement new therapies and improve adherence to HF treatments are necessary to improve outcomes in a highly comorbid and at-risk population.
Ma et al. (Sun,) conducted a cohort in Heart failure and kidney dysfunction (n=1,401). Guideline-directed medical therapy vs. eGFR ≥60 mL/min/1.73 m2 was evaluated on Heart failure therapy use and dose intensity. Severe kidney dysfunction (eGFR <30) in heart failure patients was associated with lower utilization of guideline-directed therapies like RASi (68% vs 94%) and MRA (35% vs 75%) compared to eGFR ≥60.