January 16, 2026Open Access
View Full PaperMagnitude of and outcome associated with inappropriate prescribing in heart failure with reduced ejection fraction: an analysis of 50,348 patients from the Swedish Heart Failure Registry
Key Result
Exposure to ≥1 potentially inappropriate prescription in patients with HFrEF was associated with an increased 3-year risk of HF death (HR 1.13; 95% CI 1.04-1.23).
Key Points
- To investigate the prevalence, predictors, and outcomes of inappropriate prescribing in patients with heart failure and reduced ejection fraction.
- Analyzed data from the Swedish HF Registry from 2005 to 2020.
- Utilized ESC position statement criteria to identify inappropriate prescribing.
- Employed Cox proportional hazards and negative binomial regression for outcome assessment.
- 47% of patients were prescribed at least one inappropriate medication.
- Common inappropriate medications included neuroleptics (29%) and systemic steroids (10%).
- Patients taking inappropriate medications had a 3-year increase in the risk of heart failure death and hospitalizations.
Study Design
Type
Cohort (n=50,348)
Multicenter
Yes
Structured PICO
Does potentially inappropriate prescribing increase mortality and hospitalizations in patients with HFrEF?
P
Population
50,348 patients (median age 75, 29% female) with heart failure and reduced ejection fraction from the Swedish HF Registry, assessed for 3-year outcomes.
E
Exposure
Potentially inappropriate prescribing (PIP) defined by the ESC position statement (e.g., neuroleptics, systemic steroids, NSAIDs)
C
Comparator
No potentially inappropriate prescribing
O
Outcome
3-year risk of HF death, all-cause and cardiovascular death, first and recurrent HF hospitalisationshard clinical
Nearly half of HFrEF patients receive potentially inappropriate medications, which is associated with less guideline-directed medical therapy use and increased risk of mortality and heart failure hospitalizations.
Main Result
Hazard Ratio: 1.13 (95% CI 1.04–1.23)
Abstract
Abstract Aims Patients with heart failure and reduced ejection fraction (HFrEF) are frequently exposed to polypharmacy, placing them at risk of potentially inappropriate prescribing (PIP)—defined as use of drugs that may worsen HF prognosis, counteract guideline-directed medical therapies (GDMTs), or increase harmful interactions. The prevalence, predictors, and prognostic impact of PIP in HFrEF remain unclear. Therefore, the aim was to investigate the prevalence, predictors, and outcomes of PIP in a large, real-world HFrEF population. Methods Patients with HFrEF enrolled in the Swedish HF Registry (2005–2020) were included. The ESC position statement of PIP-HFrEF was used to retrieve PIP from the National Prescribed Drugs Register. Associations between PIP and outcomes were assessed using Cox proportional hazards and negative binomial regression for recurrent events. Results Among 50,348 patients (median age 75 years, 29% female), 23,583 (47%) were prescribed ≥1 PIP. The most frequent agents were neuroleptics (29%), systemic steroids (10%), and NSAIDs (6%). Independent predictors included rheumatoid arthritis (OR 3.39; 95%CI 2.92–3.94), depression (OR 3.06; 95%CI 2.74–3.42), chronic obstructive pulmonary disease (OR 1.86; 95%CI 1.76–1.98), and gout (OR 1.48; 95%CI 1.35–1.62). Patients on PIP were less likely to receive GDMT. Presence of ≥1 PIP was independently associated with increased 3-year risk of HF death (HR 1.13; 95%CI 1.04–1.23), all-cause and cardiovascular death, first and recurrent HF hospitalisations. Conclusions Nearly half of HFrEF patients received PIP medications, particularly those with multimorbidity, which was independently associated with worse outcomes and less GDMT use. Our data underscore the need for targeted strategies to reduce inappropriate prescribing in HFrEF.