Sacubitril/Valsartan Adherence and Postdischarge Outcomes Among Patients Hospitalized for Heart Failure With Reduced Ejection Fraction

Medication adherence and persistence in heart failure: A protocol for a systematic review and meta-analysis

OBJECTIVE

To study medication adherence and persistence among heart failure patients, assess the methods utilised for estimating medication adherence, and identify optimal adherence thresholds and their impact on clinical outcomes.

METHODS

A systematic search will be conducted in PubMed, Embase, CINAHL, Web of Science, and Scopus databases. Observational studies assessing medication adherence or persistence among heart failure patients via electronic healthcare databases will be included. A narrative synthesis will describe medication adherence and persistence reported and methods used to measure it. A meta-analysis will be attempted to evaluate the impact of secondary medication adherence (multiple and by drug class) on clinical outcomes, including hospitalisation, emergency visits, and mortality. The I2 statistic will be employed to study heterogeneity and the GRADE framework to evaluate evidence certainty. This protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines and is registered with the Prospective Register of Ongoing Systematic Reviews CRD42024509542.

DISCUSSION

This study aims to evaluate medication adherence and persistence in heart failure management through electronic health databases, intending to explore widely used measurement methods and their limitations, and to identify adherence thresholds associated with improved clinical outcomes. By examining these aspects, we anticipate proposing enhancements for future research and establishing desired adherence goals. This approach highlights the expected significance of our findings in advancing patient care and research methodologies.

The contemporary role of sodium-glucose co-transporter 2 inhibitor (SGLT2i) and angiotensin receptor-neprilysin inhibitor (ARNI) in the management of heart failure: State-of-the-art review

Novel therapies for heart failure with reduced ejection fraction (HFrEF) are angiotensin receptor-neprilysin inhibitor (ARNI), sodium-glucose co-transporter 2 inhibitor (SGLT2i), etc. The purpose of this review is to determine the effects of ARNI and SGLT2i in heart failure (HF), compare the impact of SGLT2i with ARNI, and finally evaluate the current data regarding the combination of these two drugs in HF. Various trials on the respective medications have shown some significant reduction in all-cause mortality and cardiovascular (CV) death. The combination of these drugs has shown more CV benefits than monotherapy. There is emerging data about these two drugs in patients with heart failure with preserved ejection fraction (HFpEF). At present, there are less head-to-head comparison trials of these two drugs. This review provides insights on the current evidence, comparative efficacy, and combination therapy of ARNI and SGLT2i in managing HF, focussing on HFrEF and HFpEF.

Real-world characteristics and use patterns of patients treated with vericiguat: A nationwide longitudinal cohort study in Germany

PURPOSE

Vericiguat reduced clinical endpoints in patients experiencing worsening heart failure in clinical trials, but its implementation outside trials is unclear.

METHODS

This retrospective analysis of longitudinally collected data was based on the IQVIA™ LRx database, which includes ~ 80% of the prescriptions of the 73 million people covered by the German statutory health insurance.

RESULTS

Between September 2021 and December 2022, vericiguat was initiated in 2916 adult patients. Their mean age was 73 ± 13 years and 28% were women. While approximately 70% were uptitrated beyond 2.5 mg, only 36% reached 10 mg. Median time to up-titration from 2.5 mg to 5 mg was 17 (quartiles: 11-33) days, and from 2.5 to 10 mg 37 (25-64) days, respectively. In 87% of the patients, adherence to vericiguat was high as indicated by a medication possession ratio of  ≥ 80%, and 67% of the patients persistently used vericiguat during the first year. Women and older patients reached the maximal dose of 10 mg vericiguat less often and received other substance classes of guideline-recommended therapy (GDMT) less frequently. The proportion of patients receiving four pillars of GDMT increased from 29% before vericiguat initiation to 44% afterwards.

CONCLUSION

In a real-world setting, despite higher age than in clinical trials, adherence and persistence of vericiguat appeared satisfactory across age categories. Initiation of vericiguat was associated with intensification of concomitant GDMT. Nevertheless, barriers to vericiguat up-titration and implementation of other GDMT, applying in particular to women and elderly patients, need to be investigated further.

Acute Heart Failure: From The Emergency Department to the Intensive Care Unit

Acute heart failure (AHF) is a frequent cause of hospitalization around the world and is associated with high in-hospital and post-discharge morbidity and mortality. This review summarizes data on diagnosis and management of AHF from the emergency department to the intensive care unit. While more evidence is needed to guide risk stratification and care of patients with AHF, hospitalization is a key opportunity to optimize evidence-based medical therapy for heart failure. Close linkage to outpatient care is essential to improve post-hospitalization outcomes.

Bridging gaps and optimizing implementation of guideline-directed medical therapy for heart failure

Despite robust scientific evidence and strong guideline recommendations, there remain significant gaps in initiation and dose titration of guideline-directed medical therapy (GDMT) for heart failure (HF) among eligible patients. Reasons surrounding these gaps are multifactorial, and largely attributed to patient, healthcare professionals, and institutional challenges. Concurrently, HF remains a predominant cause of mortality and hospitalization, emphasizing the critical need for improved delivery of therapy to patients in routine clinical practice. To optimize GDMT, various implementation strategies have emerged in the recent decade such as in-hospital rapid initiation of GDMT, improving patient adherence, addressing clinical inertia, improving affordability, engagement in quality improvement registries, multidisciplinary clinics, and EHR-integrated interventions. This review highlights the current use and barriers to optimal utilization of GDMT, and proposes novel strategies aimed at improving GDMT in HF.

Neighborhood-Level Socioeconomic Status and Prescription Fill Patterns Among Patients With Heart Failure

Importance

Medication nonadherence is common among patients with heart failure with reduced ejection fraction (HFrEF) and can lead to increased hospitalization and mortality. Patients living in socioeconomically disadvantaged areas may be at greater risk for medication nonadherence due to barriers such as lower access to transportation or pharmacies.

Objective

To examine the association between neighborhood-level socioeconomic status (nSES) and medication nonadherence among patients with HFrEF and to assess the mediating roles of access to transportation, walkability, and pharmacy density.

Design, Setting, and Participants

This retrospective cohort study was conducted between June 30, 2020, and December 31, 2021, at a large health system based primarily in New York City and surrounding areas. Adult patients with a diagnosis of HF, reduced EF on echocardiogram, and a prescription of at least 1 guideline-directed medical therapy (GDMT) for HFrEF were included.

Exposure

Patient addresses were geocoded, and nSES was calculated using the Agency for Healthcare Research and Quality SES index, which combines census-tract level measures of poverty, rent burden, unemployment, crowding, home value, and education, with higher values indicating higher nSES.

Main Outcomes and Measures

Medication nonadherence was obtained through linkage of health record prescription data with pharmacy fill data and was defined as proportion of days covered (PDC) of less than 80% over 6 months, averaged across GDMT medications.

Results

Among 6247 patients, the mean (SD) age was 73 (14) years, and majority were male (4340 [69.5%]). There were 1011 (16.2%) Black participants, 735 (11.8%) Hispanic/Latinx participants, and 3929 (62.9%) White participants. Patients in lower nSES areas had higher rates of nonadherence, ranging from 51.7% in the lowest quartile (731 of 1086 participants) to 40.0% in the highest quartile (563 of 1086 participants) (P < .001). In adjusted analysis, patients living in the lower 2 nSES quartiles had significantly higher odds of nonadherence when compared with patients living in the highest nSES quartile (quartile 1: odds ratio [OR], 1.57 [95% CI, 1.35-1.83]; quartile 2: OR, 1.35 [95% CI, 1.16-1.56]). No mediation by access to transportation and pharmacy density was found, but a small amount of mediation by neighborhood walkability was observed.

Conclusions and Relevance

In this retrospective cohort study of patients with HFrEF, living in a lower nSES area was associated with higher rates of GDMT nonadherence. These findings highlight the importance of considering neighborhood-level disparities when developing approaches to improve medication adherence.

Association of Depression and Adherence to Oral Anticoagulation in Patients With Atrial Fibrillation

BACKGROUND

Adherence to oral anticoagulation is essential for stroke prevention in atrial fibrillation (AF). Depression has been associated with decreased adherence to medications in multiple disease states and in AF is further associated with increased risk of stroke. We hypothesized that individuals with depression and AF have decreased adherence to anticoagulation than those without depression.

METHODS AND RESULTS

We used administrative claims data to identify individuals with AF initiating anticoagulation with direct-acting oral anticoagulants (DOACs) or warfarin between 2013 and 2019. We quantified adherence using proportion of days covered, categorized as limited (proportion of days covered, <80%), adequate (proportion of days covered, ≥80% to <90%), or optimal (proportion of days covered, ≥90%). We related depression to 12-month adherence to anticoagulation in logistic regression models, adjusting for demographics, medical and psychiatric comorbidities, household income, educational attainment, and insurance type. As a secondary analysis, we determined the association of depression to adherence for each DOAC agent. We identified 101 041 individuals (aged 74.5±8.9 years; 50.6% women; 29.5% race or ethnicity other than White, including Asian or Black race and Hispanic ethnicity) who initiated either DOACs or warfarin. The odds of adequate adherence to DOACs was 11% (95% CI, 0.85-0.93), and the odds of optimal adherence was 12% (95% CI, 0.83-0.91) less in individuals with depression than those without. Depression was not associated with adherence to warfarin.

CONCLUSIONS

We identified an association between depression and decreased adherence to DOACs but not warfarin in individuals with AF. Recognizing depression in AF may guide interventions to improve anticoagulation adherence and reduce stroke risk.

Longitudinal Trajectory Modeling to Assess Adherence to Sacubitril/Valsartan among Patients with Heart Failure

Medication adherence in chronic conditions is a long-term process. Modeling longitudinal trajectories using routinely collected prescription data is a promising method for describing adherence patterns and identifying at-risk groups. The study aimed to characterize distinct long-term sacubitril/valsartan adherence trajectories and factors associated with them in patients with heart failure (HF). Subjects with incident HF starting sac/val in 2017-2018 were identified from the Campania Regional Database for Medication Consumption. We estimated patients' continuous medication availability (CMA9; R package AdhereR) during a 12-month period. We selected groups with similar CMA9 trajectories (Calinski-Harabasz criterion; R package kml). We performed multinomial regression analysis, assessing the relationship between demographic and clinical factors and adherence trajectory groups. The cohort included 4455 subjects, 70% male. Group-based trajectory modeling identified four distinct adherence trajectories: high adherence (42.6% of subjects; CMA mean 0.91 ± 0.08), partial drop-off (19.6%; CMA 0.63 ± 0.13), moderate adherence (19.3%; CMA 0.54 ± 0.11), and low adherence (18.4%; CMA 0.17 ± 0.12). Polypharmacy was associated with partial drop-off adherence (OR 1.194, 95%CI 1.175-1.214), while the occurrence of ≥1 HF hospitalization (OR 1.165, 95%CI 1.151-1.179) or other hospitalizations (OR 1.481, 95%CI 1.459-1.503) were associated with low adherence. This study found that tailoring patient education, providing support, and ongoing monitoring can boost adherence within different groups, potentially improving health outcomes.

Incidence of atrial and ventricular arrhythmias in obese patients with heart failure with reduced ejection fraction treated with sacubitril/valsartan

AIM

To compare clinical outcomes among patients with heart failure and reduced ejection fraction (HFrEF) according to body mass index (BMI) after initiating treatment with an angiotensin-receptor neprilysin inhibitor (ARNI).

METHODS

We gathered data from 2016 to 2020 at the University Medical Center Mannheim; 208 consecutive patients were divided into two groups according to BMI (< 30 kg/m2 ; n = 116, ≥ 30 kg/m2 ; n = 92). Clinical outcomes, including mortality rate, all-cause hospitalizations and congestion, were systematically analysed.

RESULTS

At the 12-month follow-up, the mortality rate was similar in both groups (7.9% in BMI < 30 kg/m2 vs. 5.6% in BMI ≥ 30 kg/m2 ; P = .76). All-cause hospitalization before ARNI treatment was comparable in both groups (63.8% in BMI < 30 kg/m2 vs. 57.6% in BMI ≥ 30 kg/m2 ; P = .69). After ARNI treatment, the hospitalization rate was also comparable in both groups at the 12-month follow-up (52.2% in BMI < 30 kg/m2 vs. 53.7% in BMI ≥ 30 kg/m2 ; P = .73). Obese patients experienced more congestion compared with non-obese patients at follow-up, without statistical significance (6.8% in BMI < 30 kg/m2 vs. 15.5% in BMI ≥ 30 kg/m2 ; P = .11). Median left ventricular ejection fraction (LVEF) improved in both groups, but significantly more in non-obese compared with obese patients at the 12-month follow-up (from 26% [3%-45%] [min.-max.] vs. 29% [10%-45%] [min.-max.] [P = .56] to 35.5% [15%-59%] [min.-max.] vs. 30% [13%-50%] [min.-max.] [P = .03], respectively). The incidence of atrial fibrillation (AF), non-sustained (ns) and sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) was less in non-obese than in obese patients after initiation of sacubitril/valsartan at the 12-month follow-up (AF: 43.5% vs. 53.7%; P = .20; nsVT: 9.8% vs. 28.4%; P = .01; VT: 14.1% vs. 17.9%; P = .52; VF: 7.6% vs. 13.4%; P = .23).

CONCLUSIONS

The incidence of congestion in obese patients was higher compared with non-obese patients. LVEF improved significantly more in non-obese compared with obese HFrEF patients. Furthermore, AF and the ventricular tachyarrhythmia rate were revealed more in obesity compared with those without obesity at the 12-month follow-up.

Using Sacubitril/Valsartan to Decrease Health care Costs in Population Health Patients

Value-based care is the foundation of population health. The Health care Economic Efficiency Ratio (HEERO) scoring system is a promising new tool to measure the cost benefits of care in our Accountable Care Organization. HEERO score compares actual costs spent (utilizing insurance claims) and expected costs spent (estimated using the Centers for Medicare/Medicaid Services Risk score). Scores <1 suggest economic benefit. Sacubitril/valsartan has been shown to decrease readmissions for patients with heart failure (HF) and decrease health care costs. We explored the utility of sacubitril/valsartan in reducing HEERO scores and decreasing overall health care expenditure in patients with HF. Patients with HF in the population health cohort were enrolled. HEERO score was calculated for patients taking sacubitril/valsartan and other HF medications at 3-month intervals up to a year. We compared the average and total health care expenditure and inpatient days for patients on sacubitril/valsartan, spironolactone, β blocker (BB) along with spironolactone, BB and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. For patients on sacubitril/valsartan, HEERO scores and inpatient days decreased (decreased health care expenditure) as the number of days of utilization increased (p <0.0001). In total, 270+ days of sacubitril/valsartan decreased health care costs by 22%. This cost reduction was mainly attributed to decreased inpatient days. Additionally, the combination of sacubitril/valsartan, spironolactone, and BB showed decreased HEERO score and inpatient days compared with spironolactone, BB and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in male patients. Sacubitril/valsartan use beyond 270 days resulted in decreased health care expenditure in a population health cohort compared with other HF medications. This economic benefit is achieved through the reduction in hospitalizations. Sacubitril/valsartan is an integral part of value-based care providing high-value, cost-effective care, and bolstering the economic wellbeing of patient care. Payor sources should consider this in subsidizing the cost of the medicine.

Novel Strategies to Improve Prescription of Guideline-Directed Medical Therapy in Heart Failure

PURPOSE OF REVIEW

To examine the emerging data for novel strategies being studied to improve use and dose titration of guideline-directed medical therapy (GDMT) for patients with heart failure (HF).

RECENT FINDINGS

There is mounting evidence to employ novel multi-pronged strategies to address HF implementation gaps.

SUMMARY

Despite high-level randomized evidence and clear national society recommendations, a large gap persists in use and dose titration of guideline-directed medical therapy (GDMT) in patients with heart failure (HF). Accelerating the safe implementation of GDMT has proven to reduce the morbidity and mortality associated with HF but remains an ongoing challenge for patients, clinicians, and health systems. In this review, we examine the emerging data for novel strategies to improve the use of GDMT including the use of multidisciplinary team-based approaches, nontraditional patient encounters, patient messaging/engagement, remote patient monitoring, and electronic health record (EHR)-based clinical alerts. While societal guidelines and implementation studies have focused on heart failure with reduced ejection fraction (HFrEF), expanding indications and evidence for the use of sodium glucose cotransporter2 (SGLT2i) will necessitate implementation efforts across the LVEF spectrum.

Association Between Copayment Amount and Filling of Medications for Angiotensin Receptor Neprilysin Inhibitors in Patients With Heart Failure

Background Angiotensin receptor neprilysin inhibitors (ARNI) reduce mortality and hospitalization for patients with heart failure. However, relatively high copayments for ARNI may contribute to suboptimal adherence, thus potentially limiting their benefits. Methods and Results We conducted a retrospective cohort study within a large, multi-site health system. We included patients with: ARNI prescription between November 20, 2020 and June 30, 2021; diagnosis of heart failure or left ventricular ejection fraction ≤40%; and available pharmacy or pharmacy benefit manager copayment data. The primary exposure was copayment, categorized as $0, $0.01 to $10, $10.01 to $100, and >$100. The primary outcome was prescription fill nonadherence, defined as the proportion of days covered <80% over 6 months. We assessed the association between copayment and nonadherence using multivariable logistic regression, and nonbinarized proportion of days covered using multivariable Poisson regression, adjusting for demographic, clinical, and neighborhood-level covariates. A total of 921 patients met inclusion criteria, with 192 (20.8%) having $0 copayment, 228 (24.8%) with $0.01 to $10 copayment, 206 (22.4%) with $10.01 to $100, and 295 (32.0%) with >$100. Patients with higher copayments had higher rates of nonadherence, ranging from 17.2% for $0 copayment to 34.2% for copayment >$100 (P<0.001). After multivariable adjustment, odds of nonadherence were significantly higher for copayment of $10.01 to $100 (odds ratio [OR], 1.93 [95% CI, 1.15-3.27], P=0.01) or >$100 (OR, 2.58 [95% CI, 1.63-4.18], P<0.001), as compared with $0 copayment. Similar associations were seen when assessing proportion of days covered as a proportion. Conclusions We found higher rates of not filling ARNI prescriptions among patients with higher copayments, which persisted after multivariable adjustment. Our findings support future studies to assess whether reducing copayments can increase adherence to ARNI and improve outcomes for heart failure.

Assessment of Depression and Adherence to Guideline-Directed Medical Therapies Following Percutaneous Coronary Intervention

IMPORTANCE

Depression is associated with increased risk of primary and secondary cardiovascular events. Medication adherence may play an essential role.

OBJECTIVE

To evaluate the association of depression and 12-month adherence to guideline-directed medical therapies (eg, antiplatelet agents, β-blockers, renin-angiotensin-aldosterone system inhibitors [ie, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers], and statins) following percutaneous coronary intervention.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included individuals who underwent percutaneous coronary intervention from January 1, 2014, to December 31, 2019. Data were collected from a large US health claims database and analyzed between February and August 2022.

MAIN OUTCOMES AND MEASURES

Proportion of days covered (PDC) for classes of guideline-directed medical therapies, with 12-month adherence categorized as adequate (PDC ≥80% to <90%) or optimal (PDC ≥90%). Multivariable-adjusted regression models were used to evaluate the association of depression with adherence; models incorporated demographic characteristics, comorbid medical and psychiatric conditions, depression treatment, and guideline-directed medical therapy treatment adjustment. The hypothesis was that those with depression would have lower odds of either adequate or optimal adherence to agents essential for guideline-directed medical therapy.

RESULTS

Of 124 443 individuals (mean [SD] age, 69.3 [10.6] years; 41 430 [33.3%] female sex; 3694 [3.0%] Asian, 12 611 [10.1%] Black, and 12 337 [9.9%] Hispanic individuals) who received percutaneous coronary interventions, 20 711 (16.6%) had a diagnosis of depression. Those with depression were significantly less likely to obtain adequate 12-month adherence to antiplatelets (odds ratio [OR], 0.80; 95% CI, 0.77-0.85), β-blockers (OR, 0.84; 95% CI, 0.80-0.88), and statins (OR, 0.88; 95% CI, 0.85-0.93) than those without depression; there was no association between depression and adherence to renin-angiotensin-aldosterone system inhibitors (OR, 0.93; 95% CI, 0.85-1.00). Those with depression had similarly decreased likelihood of optimal 12-month adherence to antiplatelets, β-blockers, and statins as well as renin-angiotensin-aldosterone system inhibitors (OR, 0.87; 95% CI, 0.82-0.94).

CONCLUSIONS AND RELEVANCE

In this cohort study, patients with depression were less likely to achieve adequate or optimal adherence to medications essential to guideline-directed medical therapies following percutaneous coronary intervention compared with those without depression. Recognition of depression may facilitate targeted interventions to address medication adherence and thereby improve secondary cardiovascular disease prevention.

Contemporary Data on the Status and Medical Management of Acute Heart Failure

PURPOSE OF REVIEW

Acute heart failure (AHF) is among the leading causes for unplanned hospital admission. Despite advancements in the management of chronic heart failure, the prognosis of AHF remains poor with high in-hospital mortality and increased rates of unfavorable post-discharge outcomes. With this review, we aim to summarize current data on AHF epidemiology, focus on the different patient profiles and classifications, and discuss management, including novel therapeutic options in this area.

RECENT FINDINGS

There is significant heterogeneity among patients admitted for AHF in their baseline characteristics, heart failure (HF) aetiology and precipitating factors leading to decompensation. A novel classification scheme based on four distinct clinical scenarios has been included in the most recent ESC guidelines, in an effort to better risk stratify patients and guide treatment. Intravenous diuretics, vasodilators, and inotropes remain the cornerstone of management in the acute phase, and expansion of use of mechanical circulatory support has been noted in recent years. Meanwhile, many treatments that have proved their value in chronic heart failure demonstrate promising results in the setting of AHF and research in this field is currently ongoing. Acute heart failure remains a major health challenge with high in-hospital mortality and unfavorable post-discharge outcomes. Admission for acute HF represents a window of opportunity for patients to initiate appropriate treatment as soon as possible after stabilization. Future studies are needed to elucidate which patients will benefit the most by available therapies and define the optimal timing for treatment implementation.

Adherence to therapy and the risk of cardiovascular events in patients with heart failure: data from the outpatient registry

Aim. To determine the adherence to drug therapy and the prevalence of cardiovascular events (CVEs) in patients with heart failure (HF) after a 1-year follow-up in a specialized cardiology unit of a research center.

Material and methods. CVEs were analyzed within the prospective observational study COMPLIANCE (Assessment of adherenСe tO Medical theraРy and its infLuence on long-term outcomes In pAtieNts with Chronic hEart failure in the outpatient registry). The study included 72 patients with HF, verified according to clinical guidelines. Patients were divided into 2 groups: adherent and non-adherent to treatment. Overall adherence to therapy and adherence to specific drugs were assessed using the original National Society for Evidence-Based Pharmacotherapy

Adherence Scale. The study included 2 visits: inclusion in the study and a visit after 1-year follow-up. After a 1-year follow-up, a comparative analysis of the two groups was performed to achieve the primary composite endpoint: death, acute cerebrovascular accident, myocardial infarction, decompensated HF with and without hospitalization.

Results. A Kaplan-Meier analysis of 1-year survival showed that the mean time to onset of primary composite endpoint was 10,2 (95% confidence interval: 9,5-10,8) months. A significant relationship was found between the occurrence of composite endpoint and adherence to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (p=0,001), which was not confirmed for beta-blockers and mineralocorticoid receptor antagonists (p=0,338 and p=0,335, respectively). The risk of composite endpoint was 3,6 times higher in non-adherent patients than in adherent patients (hazard ratio, 3,6; 95% confidence interval, 1,5-8,5 (p=0,003)).

Conclusion. A significant relationship was found between nonadherence to treatment and the incidence of CVEs, the risk of which increases by 3,6 times in non-adherent patients compared with adherent patients with HF.

Reviewing the Modern Therapeutical Options and the Outcomes of Sacubitril/Valsartan in Heart Failure

Sacubitril/valsartan (S/V) is a pharmaceutical strategy that increases natriuretic peptide levels by inhibiting neprilysin and regulating the renin-angiotensin-aldosterone pathway, blocking AT1 receptors. The data for this innovative medication are mainly based on the PARADIGM-HF study, which included heart failure with reduced ejection fraction (HFrEF)-diagnosed patients and indicated a major improvement in morbidity and mortality when S/V is administrated compared to enalapril. A large part of the observed favorable results is related to significant reverse cardiac remodeling confirmed in two prospective trials, PROVE-HF and EVALUATE-HF. Furthermore, according to a subgroup analysis from the PARAGON-HF research, S/V shows benefits in HFrEF and in many subjects having preserved ejection fraction (HFpEF), which indicated a decrease in HF hospitalizations among those with a left ventricular ejection fraction (LVEF) < 57%. This review examines the proven benefits of S/V and highlights continuing research in treating individuals with varied HF characteristics. The article analyses published data regarding both the safeness and efficacy of S/V in patients with HF, including decreases in mortality and hospitalization, increased quality of life, and reversible heart remodeling. These benefits led to the HF guidelines recommendations updating and inclusion of S/V combinations a key component of HFrEF treatment.

Sacubitril/valsartan use patterns among older adults with heart failure in clinical practice: a population-based cohort study of >25 000 Medicare beneficiaries

AIMS

Sacubitril/valsartan is strongly supported in guidelines for the management of heart failure, but suboptimal adherence and treatment non-persistence may limit the population-level benefit that this therapy might otherwise offer.

METHODS AND RESULTS

We identified a cohort of Medicare beneficiaries (2014-2017) initiating sacubitril/valsartan after ≥6 months of continuous enrolment. We assessed adherence as the proportion of days covered (PDC) and proportion of patients non-persistent (having no prescription available) at 180 days after initiation. We fit a multivariable negative binomial model with a count of adherent days to evaluate independent factors associated with of sacubitril/valsartan adherence. Among 27 063 new sacubitril/valsartan users, most (n = 17 663, 65%) were prescribed low-dose at 24 mg/26 mg and most (n = 19 984, 74%) were switched from prior angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB) rather than being RASi treatment naïve. Median 180-day PDC was 86% (25th-75th percentiles 58-98%). Black patients, those with high comorbid disease burden (≥8 comorbidities), and patients with recent hospitalization within 30 days had fewer adherent days, while those treated with preceding ACEi/ARB had more adherent days. Thirty-four percent of patients did not have an active sacubitril/valsartan prescription at day 180. Among these, few had preceding dose down-titrations (6% among patients on 49 mg/51 mg and 9% among patients on 97 mg/103 mg) and 68% did not have a subsequent ACEi/ARB prescription. Among patients who remained persistent, dose up-titrations occurred in 29% of patients who started on 24 mg/26 mg and 27% of patients on 49 mg/51 mg.

CONCLUSIONS

Overall adherence to sacubitril/valsartan among Medicare beneficiaries is acceptable, but is lower in Black patients, those with higher comorbidities or those who started therapy after recent hospitalization. While broad implementation of guideline-directed medical therapy is a key priority, additional focused efforts to improve adherence early after hospitalization and among at-risk patients are needed in parallel.

Evolving therapeutic strategies for patients hospitalized with new or worsening heart failure across the spectrum of left ventricular ejection fraction

Heart failure (HF) is a chronic, progressive, and increasingly prevalent syndrome characterized by stepwise declines in health status and residual lifespan. Despite significant advancements in both pharmacologic and nonpharmacologic management approaches for chronic HF, the burden of HF hospitalization-whether attributable to new-onset (de novo) HF or worsening of established HF-remains high and contributes to excess HF-related morbidity, mortality, and healthcare expenditures. Owing to a paucity of evidence to guide tailored interventions in this heterogeneous group, management of acute HF events remains largely subject to clinician discretion, relying principally on alleviation of clinical congestion, as-needed correction of hemodynamic perturbations, and concomitant reversal of underlying trigger(s). Following acute stabilization, the subsequent phase of care primarily involves interventions known to improve long-term outcomes and rehospitalization risk, including initiation and optimization of disease-modifying pharmacotherapy, targeted use of adjunctive therapies, and attention to contributing comorbid conditions. However, even with current standards of care many patients experience recurrent HF hospitalization, or after admission incur worsening clinical trajectories. These patterns highlight a persistent unmet need for evidence-based approaches to inform in-hospital HF care and call for renewed focus on urgent implementation of interventions capable of ameliorating risk of worsening HF. In this review, we discuss key contemporary and emerging therapeutic strategies for patients hospitalized with de novo or worsening HF.

The use of multidisciplinary teams, electronic health records tools, and technology to optimize heart failure population health

PURPOSE OF REVIEW

Given the limited population level, adoption of optimal therapy that has been shown in recent clinical trials and heart failure registries, efforts to rapidly and safely improve adoption of guideline-directed medical therapy for heart failure should be prioritized. Opportunities to leverage remote monitoring technology, the electronic health record (EHR), and multidisciplinary teams to improve heart failure care merit review.

RECENT FINDINGS

Dedicated multidisciplinary teams employing algorithmic medication titration schema have shown better efficacy than clinician alerts or quality initiatives that focus on education and audit-feedback processes alone. Technology that enables invasive pressure monitoring and wearable devices that transmit physiologic data have the potential to predict decompensation and allow for early intervention by alerting clinicians to signs of congestion/clinical worsening but further real-world data is needed to prove efficacy and develop effective treatment protocols.

SUMMARY

The combination of technology, multidisciplinary teams, and identification of populations for intervention using the EHR will be central to impactful innovation in heart failure population health and prevention of avoidable morbidity. Novel approaches to study implementation efforts including cluster randomized trials are needed.