Evaluation of the Usage and Dosing of Guideline-Directed Medical Therapy for Heart Failure With Reduced Ejection Fraction Patients in Clinical Practice

Abstract

Background: Although strategies for optimization of pharmacologic therapy in patients with heart failure with reduced ejection fraction (HFrEF) are scripted by guidelines, data from HF registries suggests that guideline-directed medical therapies (GDMT) are underutilized among eligible patients. Whether this discrepancy reflects medication intolerance, contraindications, or a quality of care issue remains unclear. Objective: The objective of this initiative was to identify reasons for underutilization and under-dosing of HFrEF therapy in patients at a large, academic medical center. Methods: Among 500 patients with HFrEF enrolled in a quality improvement project at a tertiary center, we evaluated usage and dosing of 4 categories of GDMT: ACE inhibitors/Angiotensin Receptor Blockers (ACE-i/ARB), Angiotensin Receptor-Neprilysin Inhibitors (ARNi), beta blockers, and Mineralocorticoid Receptor Antagonists (MRA). Reasons for nonprescription and usage of suboptimal doses were abstracted from notes in the chart and from telephone review of previous medication trials with the patient. Results: Of 500 patients identified, 472 subjects had complete data for analysis. Among eligible patients, ACE-i/ARB were prescribed in 81.4% (293 of 360) and beta blockers in 94.4% (442 of 468). Of these patients, 10.6% were prescribed target doses of ACE-i/ARB and 12.4% were prescribed target doses of beta blockers. Utilization of other categories of GDMT was lower, with 54% of eligible patients prescribed MRAs and 27% prescribed an ARNi. In most cases, the reasons for nonprescription or under-dosing of GDMT were not apparent on review of the health record or discussion with the patient. Conclusion: Clear rationale for nonprescription and under-dosing of GDMT often cannot be ascertained from detailed review and is only rarely related to documented medication intolerance or contraindications, suggesting an opportunity for quality improvement.

Adherence to Treatment Guidelines in Ambulatory Heart Failure Patients with Reduced Ejection Fraction in a Latin-American Country: Observational Study of the Colombian Heart Failure Registry (RECOLFACA)

“…On the other hand, ARNI therapy was observed to be importantly underused, and this action was similar to the results of registry-based studies such as the CHAMP-HF registry (13%) but lower than that reported in the study of Smith et al (27%) [24,25]. Regarding the history of this medication, the US Food and Drug Administration (FDA) approved the ARNI sacubitril/valsartan (S/V) for patients with HFrEF in July 2015 after the important results of the PARADIGM-HF trial, in which S/V reduced the risk of cardiovascular death or hospitalization for HF in 20% compared to placebo [26].…”

Clinician challenges to evidence‐based prescribing for heart failure and reduced ejection fraction: A qualitative evaluation

“…Estimates suggest many patients with heart failure with reduced ejection fraction (HFrEF) are not prescribed recommended medications, despite compelling evidence demonstrating decreased mortality and hospitalisations with improved quality of life 1–8 . Researchers have previously explored reasons for suboptimal prescribing for HFrEF and identified multifactorial issues that persist among primary care and cardiology settings 5,8–11 .…”

“…Estimates suggest many patients with heart failure with reduced ejection fraction (HFrEF) are not prescribed recommended medications, despite compelling evidence demonstrating decreased mortality and hospitalisations with improved quality of life. [1][2][3][4][5][6][7][8] Researchers have previously explored reasons for suboptimal prescribing for HFrEF and identified multifactorial issues that persist among primary care and cardiology settings. 5,[8][9][10][11] These issues include clinical inertia (i.e., delayed intervention or treatment to target), 12 cost, fear of adverse effects, clinician knowledge, and competing patient priorities.…”

Stellate Ganglia and Cardiac Sympathetic Overactivation in Heart Failure

“…The role of cardiac sympathetic hyperactivation in HF is highlighted by the use of β-blockers and cardiac sympathetic denervation as the key approach to the current therapy of HF [ 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ]. However, such pharmacological treatment may not be ideal because some studies have demonstrated that β-blockers do not provide satisfactory protection against sudden cardiac death, and some patients are either intolerant or refractory to this therapy [ 44 , 45 , 46 , 47 , 48 , 49 , 50 ]. Additionally, despite being an alternative in managing refractory ventricular arrhythmias [ 38 , 43 , 51 , 52 ], cardiac sympathetic denervation has adverse complications (including Horner’s syndrome, hyperhidrosis, paresthesia, and sympathetic fight/fight response loss) that severely limit the use of procedures in HF patients [ 53 , 54 ].…”