Assessment of eligibility for evidence-based pharmacological therapies in acute heart failure across heart failure with reduced and non-reduced ejection fraction

Initiation of guideline-directed medical therapy (GDMT) after stabilization of an acute heart failure (AHF) episode is well-tolerated and improves outcomes. In this study, we evaluated GDMT eligibility across the spectrum of left ventricular ejection fraction (LVEF) in a contemporary AHF population. Data from VancOuver CoastAL Acute Heart Failure Audit (VOCAL-AHF) of patients discharged with AHF were retrospectively analyzed. Eligibility for GDMT was determined based on major society guidelines. Heart failure phenotypes were defined as HFrEF (LVEF ≤40%), HFmrEF (41-49%), and HFpEF (≥50%). Among 1587 patients in VOCAL-AHF, there were 782 (49.3%) HFrEF, 132 (8.3%) HFmrEF, and 673 (42.4%) HFpEF. Mean age was 73±15 years and 58% were men. In HFrEF, eligibility for angiotensin receptor-neprilysin inhibitors (ARNI) was 64.4%, β-blockers 89.6%, mineralocorticoid receptor antagonists (MRA) 73.8%, and sodium-glucose cotransporter-2 inhibitor (SGLT2i) 82.2%. Overall, 64.5% were eligible for quadruple therapy. In HFmrEF, 60.6% were eligible for steroidal MRA, 66.7% for SGLT2i, and 56.8% for ARNI with 56% candidate for initiation of all three agents. Eligibility for finerenone was 62.1% based on clinical criteria and 34.1% based on strict trial criteria. Corresponding values in HFpEF were 67.4%, and 37.1%. Overall, 66.6% of patients with non-reduced EF were eligible for dual-therapy with finerenone and SGLT2i. Most patients with AHF, across LVEF categories, are eligible for in-hospital GDMT initiation, with a substantial proportion of those with non-reduced EF also meeting criteria for contemporary disease-modifying therapies, highlighting an important and previously underrecognized therapeutic opportunity in this population.