Factors associated with non-use and sub-target dosing of medical therapy for heart failure with reduced ejection fraction

Greene, Stephen J.; Tan, Xi; Yeh, Yu-Chen; Bernauer, Mark; Zaidi, Omer; Yang, Mei; Butler, Javed

doi:10.1007/s10741-021-10077-x

Cited by 23 publications

(29 citation statements)

References 75 publications

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“…This aligned with our logistic regression analysis of risk factors for ACEi/ARBs dose reduction, which also implicated older age and lower LVEF. Notably, a recent systematic review of sub‐target dosing of ACEi/ARBs identified many of the same risk factors across heterogeneous populations with HFrEF, 23 although our multivariate analysis suggests that only some are independently associated with this phenomenon.…”

Section: Discussionmentioning

confidence: 64%

Reduction of heart failure guideline‐directed medication during hospitalization: prevalence, risk factors, and outcomes

et al. 2022

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Aims Optimal management of heart failure with reduced ejection fraction (HFrEF) includes titration of guideline-directed medical therapy (GDMT) to the highest tolerated dose within the licensed range. During hospitalization, GDMT doses are often significantly altered, although it is unknown whether the cause of hospitalization influences this. Methods and resultsWe recruited 711 people with stable HFrEF from specialist heart failure clinics and prospectively assessed events occurring during first unplanned hospitalization. Dose changes of ACE inhibitors or angiotensin receptor blockers (ACEi/ARB), beta-blockers, mineralocorticoid receptor antagonists, and loop diuretics were recorded during 414 hospitalizations, categorized as due to decompensated heart failure, other cardiovascular causes, infection, or other non-cardiovascular causes. Most hospitalizations resulted in no change to GDMT. ACEi/ARB dose was reduced in 21% of hospitalizations and was more common during non-cardiovascular hospitalization (25.4% vs. 13.9%; P = 0.005). ACEi/ARB dose reduction was associated with older age and lower left ventricular ejection fraction at study recruitment, and poorer renal function, lower systolic blood pressure, higher serum potassium, and less frequent care from a cardiologist during admission. People experiencing ACEi/ARB reduction had worse age-adjusted survival after discharge, without differences in heart failure re-hospitalization. De-escalation of beta-blockers occurred in 8% of hospitalizations, most often due to other non-cardiovascular causes; this was not associated with post-discharge survival or re-hospitalization with heart failure. Conclusions De-escalation of HFrEF GDMT is more common during non-cardiovascular hospitalization and for ACEi/ARB is associated with reduced survival. Post-discharge care plans should include robust plans to consider re-escalation of GDMT in these cases.

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Section: Discussionmentioning

confidence: 64%

Reduction of heart failure guideline‐directed medication during hospitalization: prevalence, risk factors, and outcomes

et al. 2022

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“…There could be many reasons for low ARNI uptake, including clinical inertia, strict prescription criteria and patient factors. Old age and renal impairment have been implicated as reasons for low usage of ARNI and other guideline directed medical treatment, 28 and our cohort has those factors compared with drug trial populations. 15 16 There have been efforts to increase use of ARNI and other HF therapies with targeted programmes, 29 including at our centre, 30 but still only a minority of patients receive ARNI.…”

Section: Discussionmentioning

confidence: 99%

Prevalence and treatment of diabetes and pre-diabetes in a real-world heart failure population: a single-centre cross-sectional study

et al. 2022

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AimsThe aim of this study was to investigate a real-world heart failure (HF) cohort regarding (1) prevalence of known diabetes mellitus (DM), undiagnosed DM and pre-diabetes, (2) if hf treatment differs depending on glycaemic status and (3) if treatment of DM differs depending on HF phenotype.MethodsAll patients who had received a diagnosis of HF at Umeå University Hospital between 2010 and 2019 were identified and data were extracted from patient files according to a prespecified protocol containing parameters for clinical characteristics, including echocardiogram results, comorbidities, fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) values. Patients’ HF phenotype was determined using the latest available echocardiogram. The number of patients with previous DM diagnosis was assessed. Patients without a previous diagnosis of DM were classified as non-DM, pre-diabetes or probable DM according to FPG and HbA1c levels using WHO criteria.ResultsIn total, 2326 patients (59% male, mean age 76±13 years) with HF and at least one echocardiogram were assessed. Of these, 617 (27%) patients had a previous diagnosis of DM. Of the 1709 patients without a previous diagnosis of DM, 1092 (67%) patients had either an FPG or HbA1c recorded, of which 441 (41%) met criteria for pre-diabetes and 97 (9%) met criteria for probable diabetes, corresponding to 19% and 4% of the entire cohort, respectively. Patients with HF and diabetes were more often treated with diuretics and beta blockers compared with non-DM patients (64% vs 42%, p<0.001 and 88% vs 83%, p<0.001, respectively). There was no difference in DM treatment between HF phenotypes.ConclusionsDM and pre-diabetes are common in this HF population with 50% of patients having either known DM, probable DM or pre-diabetes. Patients with HF and DM are more often treated with common HF medications. HF phenotype did not affect choice of DM therapy.

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“…Accordingly, factors associated with non-use ACEIs/ARBs or MRAs were older age and worsening renal function. 12 Some switched to ARNIs, recommended in HFrEF patients with NYHA class II -III 6 .…”

Section: Discussionmentioning

confidence: 99%

“…7 A systematic review showed that the proportion of patients reaching target dose of ACEIs/ARBs, beta-blockers and MRAs was 4-55%, 4-60% and 22-80%, respectively. 12 MRAs was usually prescribed after the target dose of ACEIs/ARBs or beta-blockers has been reached. Most patients titrated to ACEIs/ARBs or MRAs target doses within 6 months but about half of beta-blockers target doses.…”

Section: The Prevalence and Characteristic Of Patients Achieve Target...mentioning

confidence: 99%

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The Prevalence and Characteristic of Patients Achieve Target Doses of Medications Used to Treat Heart Failure with Reduced Ejection Fraction at Heart Failure Clinic

2022

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To determine the prevalence and characteristics of patients who achieved target doses of angiotensin converting enzyme inhibitors (ACEIs)/ angiotensin II receptor blockers (ARBs), beta-blocker, and mineralocorticoid receptor antagonists (MRAs). MATERIALS AND METHODS:A retrospective chart review study of heart failure with reduced ejection fraction (HFrEF) patients who received ACEIs/ARBs, beta-blockers, or MRAs and follow-up more than four times at the heart failure outpatient clinic, Chonburi hospital from February 1 st , 2017 to February 29 th , 2020. Patient data were retrieved from electronic medical records. Two authors collected data into record form (CRF) independently. Achieving target doses was defined by recommended doses according to the ACC/AHA/HFSA Guideline, 2017. The comparison of continuous data was conducted with the Mann-Whitney U test. Pearson Chi-Square and Fisher's exact test were used for the comparison of categorical data. RESULTS: Patients who achieved target doses of ACEIs/ARBs, beta-blockers and MRAs was 73.3%, 55.3%, and 7.1% respectively. Patients' characteristics of achieved target doses of ACEIs/ARBs were higher baseline left ventricular ejection fractions (p = 0.026). Younger age (p = 0.016), body mass index (BMI) ≥ 23 kg/m 2 (p = 0.037; OR 5.3) and serum creatinine ≤ 2 mg/dL (p = 0.004) were the characteristics of patients who achieved target doses of beta-blockers. CONCLUSION: Most patients in heart failure clinic achieved target doses of ACEIs/ARBs followed by beta-blockers but only a few patients for MRAs. Patient and medical characteristics were different in target doses achievable.

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Factors associated with non-use and sub-target dosing of medical therapy for heart failure with reduced ejection fraction

Cited by 23 publications

References 75 publications

Reduction of heart failure guideline‐directed medication during hospitalization: prevalence, risk factors, and outcomes

Reduction of heart failure guideline‐directed medication during hospitalization: prevalence, risk factors, and outcomes

Prevalence and treatment of diabetes and pre-diabetes in a real-world heart failure population: a single-centre cross-sectional study

The Prevalence and Characteristic of Patients Achieve Target Doses of Medications Used to Treat Heart Failure with Reduced Ejection Fraction at Heart Failure Clinic

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