Insights from the Therapy of Heart Failure at Discharge (TESCODI) study: how far from full appropriateness are we in older and frail patients?

BACKGROUND Guideline-directed medical therapy (GDMT) for heart failure (HF) is often underused in older frail patients. We assessed discharge prescribing and determinants of low-prescription across Internal Medicine and Geriatrics wards in Tuscany, Italy. METHODS This prospective, multicenter, observational study included adults hospitalized for acute or acutely decompensated chronic HF (November 2024-July 2025) in 16 wards. Primary endopoint: prescription rates and change from home to discharge in the use of RAAS-i/ARNI, beta-blockers, MRAs, and SGLT2-i (McNemar's test corrected with Bonferroni rule for a = 0.0125). Predictors of under-prescription (≤2 classes at discharge) were explored using logistic regression analysis. RESULTS We enrolled 701 patients (44% male), with a median age of 85 years (IQR 80-89), 31 deceased. HFpEF 50.5%, HFmrEF 22.3%, HFrEF 22.8%. At discharge, the use of ≥3 drug classes rose from 23.4% to 55.4% (absolute +32.4 points; p < 0.001) and of all four classes from 6.6% to 24% (absolute +17.5; p < 0.001). Class-specific changes: RAAS-i 57.3%→63.1% (p = 0.056), MRAs 27.5%→58.5% (p < 0.001), beta-blockers 68.8%→84.6% (p < 0.001), SGLT2-i 22.2%→52.2% (p < 0.001). Gains were consistent across LVEF strata, although HFpEF remained less intensively treated; loop-diuretic use increased to 96% at discharge (median 75 mg furosemide-equivalent). Independent correlates of ≤2 classes were age >85 years (OR 1.58; 95% CI 1.13-2.21), eGFR <30 ml/min (OR 3.13; 1.73-5.66), BNP <760 pg/ml (OR 1.95; 1.23-3,11), and dementia (OR 1.52; 1.07-2.17). SGLT2-i were less frequently prescribed in very old patients, those with advanced CKD, and low BNP levels; RAAS-i were less used in older patients, those with AF, impaired mobility, and CKD. CONCLUSIONS Hospitalization is a pragmatic window for intensifying GDMT, even in very old, multimorbid patients. Residual gaps-especially for SGLT2-i and, to a lesser extent, RAAS-i- in the context of advanced age, dementia, and CKD call for targeted implementation strategies that balance efficacy, safety, and goals of care in frailty.