Medical Therapy for Heart Failure With Reduced Ejection Fraction
Key result
Guideline-directed medical therapy remains underutilized in HFrEF, with only ~1% simultaneously receiving target doses.
- n=3,518
Why the study?
Guidelines recommend multiple medications for HFrEF, but the degree to which gaps in medication use and dosing persist in contemporary outpatient practice is unclear.
Population
3,518 chronic HFrEF outpatients from 150 primary care and cardiology practices in the United States
Comparison
Baseline use and dose of ACEI/ARB, ARNI, beta-blocker, and MRA
Design
Registry-based observational study
Authors
Discussion
Loading...
Member takes
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
TATariq AhmadCardiologist, Yale School of Medicine
“Imagine for a moment that there is a deadly type of cancer that claims the lives of more than one-half a million Americans each year. Thankfully, there are well-tolerated therapies that offer a several-fold decrease in risk of mortality when taken together. One might expect widespread use of these treatments in patients who meet criteria, but national registry data show that only approximately 1% of the patients who qualify are prescribed appropriate doses of these therapies. It is likely that there would be public outrage and calls to action for initiatives aimed at urgent improvement. Clinicians and health care systems would be held accountable.”
“We need to turn our thinking on its head about heart failure in clinical practice.”
“In HFrEF, the four medications clearly reduce all-cause mortality, are nonoverlapping and truly and fully additive, and their benefits are cumulative, incremental, and begin within days. Yet, when we look at their actual implementation in clinical practice, we've seen this slow and variable uptake.”
Implication
There are significant gaps in the prescription and optimal dosing of guideline-directed medical therapy for HFrEF in contemporary US outpatient practice, with only 1% of eligible patients receiving target doses of all medication classes.
Key Points
- To characterize contemporary patterns and patient-level determinants of medication utilization and target dosing in outpatients with chronic heart failure with reduced ejection fraction.
- Analyzed baseline data from the CHAMP-HF registry of 3,518 outpatients with chronic heart failure with reduced ejection fraction across 150 US primary care and cardiology practices.
- Assessed utilization and target dosing across four key drug classes: ACE inhibitors/ARBs, ARNIs, beta-blockers, and MRAs, identifying clinical and socioeconomic factors associated with prescribing patterns.
- Among eligible patients, 27% were not prescribed an ACEI/ARB/ARNI, 33% were not prescribed a beta-blocker, and 67% were not prescribed an MRA.
- Target doses were achieved in only 17% of patients on ACEI/ARBs, 14% on ARNIs, and 28% on beta-blockers (versus 77% on MRAs), with only 1% receiving target doses of all three recommended drug classes simultaneously.
- Older age, lower blood pressure, higher functional class severity, renal insufficiency, and recent heart failure hospitalization were independently associated with lower medication use or dosing.
Study Design
Type
Observational (n=3,518)
Multicenter
Yes
Structured PICO
P
Population
3,518 outpatients in the United States with chronic HFrEF receiving at least 1 oral medication for management of HF.
E
Exposure
Guideline-directed medical therapy (ACEI/ARB, ARNI, beta-blocker, and MRA)
O
Outcome
Patterns and factors associated with use and dose of HFrEF medications
There are significant gaps in the prescription and optimal dosing of guideline-directed medical therapy for HFrEF in contemporary US outpatient practice, with only 1% of eligible patients receiving target doses of all medication classes.
Cite This Study
Greene et al. (2018) conducted an observational in Heart failure with reduced ejection fraction (HFrEF) (n=3,518). Guideline-directed medical therapy (ACEI/ARB/ARNI, beta-blocker, and MRA) was evaluated on Use and dose of HFrEF medications. In a contemporary US registry of HFrEF outpatients, significant gaps in guideline-directed medical therapy remain, with only 1% of eligible patients simultaneously receiving target doses.