Key result
Omission of quadruple GDMT linked to ~2.6-fold higher mortality in frail HFrEF with low BP.
Why the study?
Low blood pressure and frailty are major barriers to GDMT in HFrEF, and data on GDMT utilization and its prognostic impact in frail HFrEF patients with low blood pressure remain limited.
Does contemporary four-pillar guideline-directed medical therapy reduce all-cause mortality compared to conventional or incomplete therapy in frail patients with HFrEF and low systolic blood pressure?
Cohort (n=382)
Does contemporary four-pillar guideline-directed medical therapy reduce all-cause mortality compared to conventional or incomplete therapy in frail patients with HFrEF and low systolic blood pressure?
In frail patients with HFrEF and low discharge systolic blood pressure (≤100 mmHg), prescription of contemporary four-pillar GDMT was associated with lower all-cause and cardiovascular mortality compared to incomplete GDMT regimens.
Answers are grounded in this paper and cite their sources.
Four-pillar GDMT was associated with lower mortality in frail HFrEF with low BP; leaves open confirmation in randomized trials.
Background Low blood pressure (BP) and frailty are major barriers to guideline-directed medical therapy (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF). Data on GDMT utilization and its prognostic impact in frail patients with HFrEF and low BP remain limited. Purpose To investigate prescription patterns of GDMT and assess whether contemporary GDMT is associated with clinical outcomes in frail patients with HFrEF and low BP. Methods From the JROADHF-NEXT database, we analyzed patients hospitalized for acute HF with left ventricular ejection fraction <40%, discharge systolic BP ≤100 mmHg, and Clinical Frailty Scale (CFS) score 4–7. Patients were categorized into three groups according to discharge GDMT: group 1, ACE-I/ARB/ARNI + β-blocker + MRA + SGLT2-I; group 2, ACE-I/ARB/ARNI + β-blocker; and group 3, others. The primary outcome was all-cause mortality, and the secondary outcome was cardiovascular death. Results A total of 382 patients were included (mean age 69 ± 14 years; 68% male; median CFS 4 [IQR 4–5]). Mean discharge BP was 90 ± 7 mmHg and increased to 107 ± 21 mmHg at 12 months. At discharge, ACEI/ARB/ARNI, β-blockers, MRAs, and SGLT2-Is were prescribed in 78%, 91%, 79%, and 26% of patients, respectively, and continued in 78%, 89%, 73%, and 34% at 12 months. The contemporary GDMT (Group 1) was prescribed in 69 patients (18%), whereas conventional GDMT (Group 2) was prescribed in 194 patients (51%). During a median follow-up of 1.95 years, 100 patients (26%) died. Compared with group 1, adjusted HRs for all-cause mortality were 1.67 (95% CI 0.82–3.44, p=0.159) in group 2 and 2.63 (95% CI 1.28–5.43, p=0.009) in group 3; for cardiovascular death, the corresponding HRs were 2.00 (95% CI 0.73–5.50, p=0.175) and 3.95 (95% CI 1.47–10.6, p=0.007), respectively. Conclusion In frail patients with HFrEF and low BP, contemporary GDMT was associated with improved clinical outcomes.
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Nagumo et al. (2026) conducted a cohort in Heart failure with reduced ejection fraction (HFrEF), frailty, and low blood pressure (n=382). Contemporary GDMT (ACE-I/ARB/ARNI + β-blocker + MRA + SGLT2-I) vs. Conventional GDMT (ACE-I/ARB/ARNI + β-blocker) or other therapy was evaluated on All-cause mortality (HR 2.63 (Group 3 vs Group 1), 95% CI 1.28-5.43, p=0.009). Lack of contemporary quadruple GDMT (Group 3 vs Group 1) was associated with higher all-cause mortality in frail HFrEF patients with low BP.
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