Eligibility for the 4 Pharmacological Pillars in Heart Failure With Reduced Ejection Fraction at Discharge

Abstract

Background Guidelines recommend using multiple drugs in patients with heart failure (HF) with reduced ejection fraction, but there is a paucity of real‐world data on the simultaneous initiation of the 4 pharmacological pillars at discharge after a decompensation event. Methods and Results A retrospective data mart, including patients diagnosed with HF, was implemented. Consecutively admitted patients with HF with reduced ejection fraction were selected through an automated approach and categorized according to the number/type of treatments prescribed at discharge. The prevalence of contraindications and cautions for HF with reduced ejection fraction treatments was systematically assessed. Logistic regression models were fitted to assess predictors of the number of treatments (≥2 versus <2 drugs) prescribed and the risk of rehospitalization. A population of 305 patients with a first episode of HF hospitalization and a diagnosis of HF with reduced ejection fraction (ejection fraction, <40%) was selected. At discharge, 49.2% received 2 current recommended drugs, β‐blockers were prescribed in 93.4%, while a renin‐angiotensin system inhibitor or an angiotensin receptor–neprilysin inhibitor was prescribed in 68.2%. A mineralocorticoid receptor antagonist was prescribed in 32.5%, although none of the patients showed contraindications to mineralocorticoid receptor antagonist prescription. A sodium‐glucose cotransporter 2 inhibitor could be prescribed in 71.1% of patients. On the basis of current recommendations, 46.2% could receive the 4 foundational drugs at discharge. Renal dysfunction was associated with <2 foundational drugs prescribed. After adjusting for age and renal function, use of ≥2 drugs was associated with lower risk of rehospitalization during the 30 days after discharge. Conclusions A quadruple therapy could be directly implementable at discharge, potentially providing prognostic advantages. Renal dysfunction was the main prevalent condition limiting this approach.

Progress of patients hospitalized with acute heart failure treated with empagliflozin

“…Various studies have indicated that in clinical practice, a high number of patients with HF would be eligible for treatment with SGLT2i [ 18 , 19 ]. In fact, in a recent study that analyzed the eligibility of the four pharmacologic pillars for treatment of HFrEF at discharge from hospital, SGLT2i were more frequently prescribed than RAAS inhibitors and mineralocorticoid receptor antagonists, with kidney failure being the main factor limiting prescription of these agents, in contrast with SGLT2i [ 20 ]. Furthermore, major differences can be observed in the clinical profile and type of HF depending on the specialist treating the patient (e.g., internal medicine vs cardiology).…”

Validation of a New Scoring Method to Assess the Efficacy of Rapid Initiation and Titration of Combination Pharmacotherapy for Patients Hospitalized with Acute Decompensated Heart Failure with Reduced and Mildly Reduced Ejection Fraction

“…These studies collectively demonstrate the importance of early initiation, titration, and maintenance of GDMT. Nevertheless, real-world data indicate a number of HF patients are not receiving appropriate medications [19][20][21]. The reasons for this underuse of GDMT may be multifactorial.…”

“…However, most clinical data on HF pharmacotherapy have concerned a single drug or two [14][15][16][17], and few studies have evaluated the efficacy of titrating multiple HF agents. Moreover, a number of HF patients do not receive adequate types and doses of HF drugs in the real world, due to low systolic blood pressure and/or heart rate, advanced age, chronic renal insufficiency, electrolyte disturbances, or clinical inertia [18][19][20][21]. To address this underutilization of HF medications, there is definitely a need for practical indicators and criteria that clinicians and medical practitioners can use to promote appropriate drug prescribing.…”

Comorbidities and cardiac resynchronization therapy: Do we talk the talk or should we walk the walk?

“…According to a recent observational study enrolling patients with a first episode of HF hospitalization and a diagnosis of HFrEF, only 46.2% received the four foundational drugs at discharge, considering the contraindications and cautions stated in the European Society of Cardiology HF guidelines for each pillar 21 . Still, adherence to GDMT is associated with the best prognosis in HFrEF, with patients presenting with intolerances or contraindications having the highest risk of events.…”