Treatment of heart failure with reduced ejection fraction in England: nationwide studies using the OpenSAFELY platform from 2018 to 2024

Objectives To evaluate prescribing of guideline-recommended four-pillar therapy for heart failure with reduced ejection fraction (HFrEF) and associated sociodemographic and clinical inequalities in England before, during and after the COVID-19 pandemic and during a period evolving healthcare guidance. Design Population-based observational cohort studies. Setting Primary care in England, using data from general practices contributing to the OpenSAFELY platform, linked to national hospital admissions and mortality records. Participants Adults with coded HFrEF in primary care records were included in three cohorts: (1) pre-pandemic (1 January 2018 to 22 March 2020), (2) pandemic (23 March 2020 to 23 February 2022) and (3) post-pandemic (24 February 2022 to 1 May 2024). Patients with heart failure with preserved ejection fraction, missing key demographic data or <90 days prior registration were excluded. In the post-pandemic cohort, 221 855 patients were included; 64.2% were men and 35.5% were aged ≥80 years. Primary and secondary outcome The primary outcome was prescribing prevalence of the four guideline-recommended therapies (renin-angiotensin system inhibitor or angiotensin receptor-neprilysin inhibitor (ARNi), beta-blocker, mineralocorticoid receptor antagonist and sodium-glucose co-transporter 2 (SGLT2) inhibitor) alone and in combination. Prescribing inequalities were assessed across sociodemographic and clinical subgroups. Results Prescribing of all four pillars increased over time, reaching 15% of patients by May 2024. In the post-pandemic cohort, 16.3% of patients received no guideline-recommended therapy and 17.7% received three pillars of care. Older adults and women received fewer therapies compared with younger patients and men ((RR 80+: 0.27, 95% CI (0.24 to 0.31)) (RRmen: 1.66, 95% CI (1.54 to 1.79))). Prescribing was lower in some English regions. No differences were observed by ethnicity or socioeconomic deprivation. SGLT2 inhibitor and ARNi prescribing rose substantially after their introduction into guidelines, while beta-blocker prescribing remained stable. Conclusion Uptake of guideline-recommended HFrEF therapies has improved but remains suboptimal, with variation by age, sex and region that may reflect differences in phenotype, comorbidity and access to specialist care rather than inequality alone. Continued focus on understanding potential inequalities in prescribing is essential to optimise heart failure care in England.