Temporal trends and determinants of heart failure therapy after myocardial infarction: a PROFID subanalysis

Background Patients with heart failure with reduced ejection fraction (HFrEF) after myocardial infarction (MI) remain at high risk of adverse outcomes. Guideline-directed medical therapy reduces morbidity and mortality; however, long-term implementation patterns across heterogeneous healthcare settings are not well characterised. Purpose We evaluated temporal trends and determinants of baseline receipt of standard HFrEF therapy in post-MI patients with LVEF <40% over two decades. Methods We conducted a retrospective pooled analysis of harmonised individual-level data from multiple post-MI databases (2000–2020). The primary endpoint was baseline receipt of triple therapy consisting of an ACE inhibitor or angiotensin receptor blocker (ARB), beta-blocker, and mineralocorticoid receptor antagonist (MRA). Angiotensin receptor–neprilysin inhibitors and sodium–glucose cotransporter-2 inhibitors were excluded due to absence in historical datasets. Temporal trends and determinants were evaluated using multivariable logistic regression (complete-case primary analysis; multiple imputation sensitivity analysis). Prespecified interaction tests assessed heterogeneity by age group and database, with Benjamini–Hochberg false discovery rate adjustment. Results Among 30,830 eligible post-MI patients with HFrEF (median age 72 years; 71.5% male), baseline use of ACE inhibitor/ARB and beta-blocker was high (82.1% and 86.7%, respectively), whereas MRA use was low (10.4%). In the complete-case multivariable analysis (n=19,324; 1,914 received triple therapy), receipt of triple therapy increased over calendar time (adjusted OR per 1-year increase 1.50; 95% CI 1.47–1.53; p<0.001), yet fewer than 10% of patients received triple therapy at baseline. Age >75 years was independently associated with lower odds of triple therapy (aOR 0.72; 95% CI 0.62–0.84), whereas diabetes (aOR 1.32; 95% CI 1.17–1.48) and hypertension (aOR 1.23; 95% CI 1.10–1.37) were associated with higher odds. There was no significant heterogeneity of temporal trends by age (interaction p=0.094; FDR-adjusted p=0.187) or by database (p=0.673). Findings were consistent in sensitivity analyses. Conclusion In this large multi-database cohort of post-MI patients with HFrEF from 2000–2020, uptake of foundational triple therapy increased substantially over time but remained low overall, particularly among older patients. These findings underscore persistent gaps in the implementation of evidence-based HFrEF therapy in routine post-MI care.