A Composite Score Summarizing Use and Dosing of Evidence-Based Medical Therapies in Heart Failure: A Nationwide Cohort Study

Abstract

BACKGROUND: As heart failure therapeutic care becomes increasingly complex, a composite medical therapy score could be useful to conveniently summarize background medical therapy. We applied the composite medical therapy score developed by the Heart Failure Collaboratory (HFC) to the Danish heart failure with reduced ejection fraction population to evaluate its external validation including assessing the distribution of the score and its association with survival. METHODS: In a retrospective nationwide cohort study, we identified all Danish heart failure with reduced ejection fraction patients alive on July 1, 2018, and assessed their treatment doses. Patients were excluded if they did not have at least 365 days for up-titration of medical therapy prior to identification. The HFC score (range 0–8) accounts for use and dosing of multiple therapies prescribed to each patient. Risk-adjusted association between the composite score and all-cause mortality was examined. RESULTS: In total, 26 779 patients (mean age 71.9 years; 32% women) were identified. At baseline, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker was used in 77%, β-blocker in 81%, mineralocorticoid receptor antagonist in 30%, angiotensin receptor-neprilysin inhibitor in 2%, and ivabradine in 2%. The median HFC score was 4. After multivariable adjustment, higher HFC scores were independently associated with lower mortality (≥median versus <median: hazard ratio, 0.72 [0.67–0.78]; P <0.001). In restricted cubic spline analysis based on a fully adjusted Poisson regression model, a graded inverse association between the HFC score and death was observed, P <0.001. CONCLUSIONS: Nationwide assessment of therapeutic optimization in heart failure with reduced ejection fraction using the HFC score was feasible and the score was strongly and independently associated with survival.

A scoring evaluation for the practical introduction of guideline‐directed medical therapy in heart failure patients

“…This study separated backgrounds according to their scores and reported that the effect of dapagliflozin was constant regardless of the score. A study of Danish nationwide registries reported that higher GDMT scores were associated with improved mortality in patients with HF, similar to the results of the present study 21 . The four drugs used for scoring in this study are RAS inhibitors, BB, MRA, and ivabradine, and did not include SGLT2 inhibitors, which is the current standard therapy for HFrEF.…”

“…A study of Danish nationwide registries reported that higher GDMT scores were associated with improved mortality in patients with HF, Simple GDMT score in HF similar to the results of the present study. 21 The four drugs used for scoring in this study are RAS inhibitors, BB, MRA, and ivabradine, and did not include SGLT2 inhibitors, which is the current standard therapy for HFrEF. However, this study did not examine HF rehospitalization, another important clinical outcome.…”

DASH-HF Study: A Pragmatic Quality Improvement Randomized Implementation Trial for Patients With Heart Failure With Reduced Ejection Fraction

“…The OPS was created by the investigators, using an approach similar to that used to characterize baseline GDMT use and dosing of clinical trial participants [13][14][15] to quantify GDMT optimization (Table 1). It was calculated based on the presence of each class of GDMT and total daily dose of each medication as listed on the patient's active medications in the VA dashboard (Figure S1).…”

When the Whole Is the Sum of Its Parts: Validation of the Heart Failure Collaboratory Medication Composite Score in Denmark

“…In this issue, a group of investigators set out to calculate and validate the HF Collaboratory score in a large HFrEF population. 9 They leveraged the Danish public healthcare system to cross-linked nationwide administrative registries containing information on inpatient and outpatient contacts, redeemed prescriptions, and laboratory values. They identified all Danish adults alive on July 1, 2018, with an existing International Classification of…”

“…In this issue, a group of investigators set out to calculate and validate the HF Collaboratory score in a large HFrEF population. 9 They leveraged the Danish public healthcare system to cross-linked nationwide administrative registries containing information on inpatient and outpatient contacts, redeemed prescriptions, and laboratory values. They identified all Danish adults alive on July 1, 2018, with an existing International Classification of Diseases, Tenth Revision, Clinical Modification code of I50 (heart failure) who also had HFrEF based on a validated algorithm requiring at least 1 claimed prescription of a renin-angiotensin-system blocker and a blocker-blocker.…”