In-Hospital Guideline-Directed Medical Therapy Intensification and Long-Term Outcomes in Patients Hospitalized for Heart Failure in the Current Clinical Paradigm ― Insights From the QHEART-R Study ―

BACKGROUND: The real-world impact of in-hospital intensification of guideline-directed medical therapy (GDMT) on clinical outcomes in patients with heart failure (HF) remains uncertain. We evaluated the association between in-hospital GDMT intensification and long-term outcomes using data from the multicenter QHEART-R cohort. METHODS AND RESULTS: We analyzed 3,190 patients hospitalized for worsening HF. In-hospital GDMT intensification was quantified by the change in the simple GDMT score from admission to discharge (∆S-GDMT). The primary outcome was a composite of all-cause death or hospitalization for HF (HHF). The mean (±SD) age of the cohort was 77.7±14.0 years, 53% were male, and the mean hospital stay was 20±16 days. The cohort included 1,477 (46%) patients with HF with reduced ejection fraction (HFrEF), 435 (14%) with HF with mildly reduced ejection fraction (HFmrEF), and 1,276 (40%) with HF with preserved ejection fraction. Four-year event-free survival was 32.4% for the primary outcome, 82.5% for cardiovascular (CV) death, and 50.4% for HHF. In patients with HFrEF/HFmrEF, a greater ∆S-GDMT was independently associated with a lower risk of the primary outcome (adjusted hazard ratio 0.90; 95% confidence interval 0.86-0.93; P<0.001), regardless of the number of prior HHF or the simple GDMT score at discharge. CONCLUSIONS: In-hospital GDMT intensification was associated with improved long-term outcomes in patients with HFrEF/HFmrEF. Hospitalization represents a critical opportunity to optimize GDMT and improve prognosis.