Residence in lower- and middle-income countries was associated with lower prescription rates of all three guideline-recommended HFrEF medications at discharge (19% vs 41%) and 6 months (15% vs 37%).
Cohort (n=8,669)
Yes
What are the global disparities in the prescription of guideline-recommended drugs for HFrEF, and how do they affect 1-year mortality?
There are significant global disparities in the prescription of guideline-directed medical therapy for HFrEF, with patients in lower- and middle-income countries being significantly less likely to receive target doses, which negatively impacts 1-year survival.
Absolute Event Rate: 19% vs 41%
BACKGROUND: Heart failure (HF) is a global challenge, with lower- and middle-income countries (LMICs) carrying a large share of the burden. Treatment for HF with reduced ejection fraction (HFrEF) improves survival but is often underused. Economic factors might have an important effect on the use of medicines. METHODS AND RESULTS: This analysis assessed prescription rates and doses of renin-angiotensin system (RAS) inhibitors, β-blockers, and mineralocorticoid receptor antagonists at discharge and 6-month follow-up in 8669 patients with HFrEF (1458 from low-, 3363 from middle-, and 3848 from high-income countries) hospitalized for acute HF in 44 countries in the prospective REPORT-HF study. We investigated determinants of guideline-recommended treatments and their association with 1-year mortality, correcting for treatment indication bias.Only 37% of patients at discharge and 34% of survivors at 6 months were on all three medication classes, with lower proportions in LMICs than high-income countries (19 vs. 41% at discharge and 15 vs. 37% at 6 months). Women and patients without health insurance, or from LMICs, or without a scheduled medical follow-up within 6 months of discharge were least likely to be on guideline-recommended medical therapy at target doses, independent of confounders. Being on ≥50% of guideline-recommended doses of RAS inhibitors, and β-blockers were independently associated with better 1-year survival, regardless of country income level. CONCLUSION: Patients with HFrEF in LMICs are less likely to receive guideline-recommended drugs at target doses. Improved access to medications and medical care could reduce international disparities in outcome.
“The paper's coming out at a very good time when there's a lot of press about how much we've advanced in heart failure, all the good therapies we have, the consistency among international guidelines that we should get every patient on four foundational medicines. That is then juxtaposed to this reality check that we're not even doing right by our patients with the basic three, and especially women, especially those from low-income regions, and especially those without any insurance.”
Tromp et al. (Tue,) conducted a cohort in Heart failure with reduced ejection fraction (HFrEF) (n=8,669). Lower- and middle-income country (LMIC) residence vs. High-income country residence was evaluated on Prescription of all three guideline-recommended medication classes at discharge. Residence in lower- and middle-income countries was associated with lower prescription rates of all three guideline-recommended HFrEF medications at discharge (19% vs 41%) and 6 months (15% vs 37%).
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