Global disparities in prescription of guideline-recommended drugs for heart failure with reduced ejection fraction
Key result
Residence in lower- and middle-income countries is linked to ~54% lower HFrEF triple therapy prescription.
- n=8,669
Why the study?
HFrEF treatments improve survival but are underused, and economic factors may strongly influence medication use globally, particularly in lower- and middle-income countries.
What are the global disparities in the prescription of guideline-recommended drugs for HFrEF, and how do they affect 1-year mortality?
Population
8669 patients with HFrEF hospitalized for acute HF across 44 countries
Comparison
Patients from low- vs middle- vs high-income countries
Design
Prospective cohort study (REPORT-HF)
Follow-up
1-year
Authors
Discussion
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Member takes
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The paper's coming out at a very good time when there's a lot of press about how much we've advanced in heart failure, all the good therapies we have, the consistency among international guidelines that we should get every patient on four foundational medicines. That is then juxtaposed to this reality check that we're not even doing right by our patients with the basic three, and especially women, especially those from low-income regions, and especially those without any insurance.”
DCDr. Carolyn Lam
“The overall low use of GDMT for heart failure on a worldwide scale among centers collecting data in a standard way is consistent with prior research conducted within single countries or regions. I think the surprising part [is] just how bad we are at this as a whole.”
Implication
May signal economic barriers to GDMT uptake in LMICs; leaves open causal mechanisms and need for prospective confirmation.
Key Points
- This analysis explores prescription rates of guideline-recommended medications for patients with heart failure and investigates factors affecting disparities across income levels.
- Analyzed data from 8669 patients with heart failure with reduced ejection fraction in 44 countries.
- Assessed prescription rates and doses of renin-angiotensin system inhibitors, β-blockers, and mineralocorticoid receptor antagonists at discharge and 6-month follow-up.
- Investigated determinants of treatment and their association with 1-year mortality, correcting for treatment indication bias.
- Only 37% of patients were prescribed all three medication classes at discharge, with disparities between low- and middle-income countries (19%) versus high-income countries (41%).
- At 6 months, 34% of survivors remained on all three medications, with lower rates in low- and middle-income countries compared to high-income.
- Being on ≥50% of guideline-recommended doses was associated with improved 1-year survival, irrespective of income level.
Study Design
Type
Cohort (n=8,669)
Multicenter
Yes
Structured PICO
What are the global disparities in the prescription of guideline-recommended drugs for HFrEF, and how do they affect 1-year mortality?
P
Population
8,669 patients with HFrEF hospitalized for acute heart failure across 44 countries, followed for up to 1 year.
E
Exposure
Guideline-recommended medical therapy (renin-angiotensin system inhibitors, β-blockers, and mineralocorticoid receptor antagonists)
O
Outcome
Prescription rates and doses of renin-angiotensin system inhibitors, β-blockers, and mineralocorticoid receptor antagonists at discharge and 6-month follow-up, and 1-year mortality
Main Result
Absolute Event Rate: 19% vs 41%
There are significant global disparities in the prescription of guideline-directed medical therapy for HFrEF, with patients in lower- and middle-income countries being significantly less likely to receive target doses, which negatively impacts 1-year survival.
Cite This Study
Tromp et al. (2022) conducted a cohort in Heart failure with reduced ejection fraction (HFrEF) (n=8,669). Lower- and middle-income country (LMIC) residence vs. High-income country residence was evaluated on Prescription of all three guideline-recommended medication classes at discharge. Residence in lower- and middle-income countries was associated with lower prescription rates of all three guideline-recommended HFrEF medications at discharge (19% vs 41%) and 6 months (15% vs 37%).