Patient Eligibility for Established and Novel Guideline-Directed Medical Therapies After Acute Heart Failure Hospitalization

Eligibility and GDMT up-titration success in heart failure: A real-world assessment

BACKGROUND

Implementation of GDMT in HFrEF remains incomplete. Prescription manners may vary based on the development of adverse effects. An HFA position paper proposed patient profiling and individualized prescription manners. This study aims to assess the eligibility for GDMT up-titration and its success in the context of clinical profiles in chronic severe HFrEF outpatients.

METHODS

Clinical characteristics of 900 HFrEF patients at first presentation were assessed, and GDMT up-titration limiting factors were identified by applying thresholds of mutual consent. GDMT prescription was analyzed at 6 months and 1 year.

RESULTS

75% of patients had no GDMT up-titration limiting factor at baseline. Significant up-titration could be achieved in all four HF drug classes, especially within the first 6 months, irrespective of GDMT up-titration limiting factors (p ≤ 0.035 for administration and dosage, all drug classes). During up-titration, there was a balanced transition between up-titration limiting factors. 35% of patients received triple therapy on target dosages with a 2.6% one-year mortality rate. Regarding the HFA profiles, 62% of patients could not be classified into a specific HFA phenotype, including most severe patients. 98% of classifiable patients belonged to only four phenotypes, while GDMT up-titration could be achieved in all of these HFA profiles (p ≤ 0.007).

CONCLUSION

In this real-world study, 75% of patients with chronic severe HFrEF are eligible for GDMT up-titration towards target dosages. The clinical profile concept of the HFA might be adapted, as most classifiable patients can be up-titrated, and most severe patients are missed by the classification.

Eligibility of Outpatients with Chronic Heart Failure for Vericiguat and Omecamtiv Mecarbil: From Clinical Trials to the Real-World Practice

Background: Several drugs are emerging as potential therapeutic resources in the context of chronic heart failure (CHF), although their impact on daily clinical practice remains unknown. The objective of this study was to investigate the theoretical eligibility for vericiguat and omecamtiv mecarbil (OM) in a real-world outpatient setting. Methods: A cross-sectional observational study was conducted, enrolling all patients with CHF who had at least one visit between January 2023 and January 2024 in a dedicated outpatient clinic of a tertiary referral center. Theoretical eligibility for vericiguat and OM in our population was assessed by adopting the criteria of the respective phase III clinical trials (VICTORIA trial for vericiguat and GALACTIC-HF trial for OM). Results: In 350 patients with CHF, the rate of individuals eligible was 2% for vericiguat and 4% for OM. A value for left ventricular ejection fraction (LVEF) over the clinical trials' cutoffs was observed in 41% of cases for vericiguat and 69% for OM. The absence of a recent heart failure (HF) worsening was found in 78% of cases for vericiguat and 72% for OM. Conclusions: Only a small proportion of CHF patients would be eligible for vericiguat and OM in a real-world outpatient setting. The absence of a recent HF worsening and an LVEF over the established trials' cutoffs are the main causes of non-eligibility. Further studies are required to assess the efficacy of these drugs in a wider population in order to increase the candidates for these beneficial treatments.

Effect of sodium-glucose Co-transporter 2 inhibitors on coronary microcirculation

Coronary microvascular disease (CMVD) has emerged as a new target for the occurrence and development of heart failure treatment. Various indicators such as Index of Microvascular Resistance, Coronary Flow Reserve, Microvascular Resistance Reserve, Hyperemic Microvascular Resistance and Coronary Flow Velocity Reserve can be used to assess CMVD. Coronary microcirculation dysfunction is one of the important pathogenic mechanisms of heart failure. Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors have been widely used in the treatment of various types of heart failure, but their specific pharmacological mechanisms are not yet fully understood. Studies have shown that SGLT2 inhibitors may be involved in the pathophysiology of CMVD by regulating cellular pathophysiological processes such as oxidative stress, mitochondrial function, energy metabolism, vascular genesis, and signalling pathways. Therefore, coronary microvascular dysfunction may be one of the treatment targets of using SGLT2 inhibitors in heart failure. Several animal experiments have found that SGLT2 inhibitors can improve microcirculatory dysfunction. However, the results of several clinical trials on the effects of SGLT2 inhibitors on coronary microcirculation have been different. Therefore, it is still lack of conclusive evidence on the effects of SGLT2 inhibitors on microcirculatory dysfunction. This review aims to summarize the completed and ongoing experiments regarding the effects of SGLT2 inhibitors on coronary microcirculation, in order to better elucidate the impact of SGLT2 inhibitors on microcirculation. It seeks to provide valuable information for the pharmacological mechanisms of SGLT2 inhibitors, the study of diseases related to coronary microcirculation disorders, and the treatment of heart failure.

Guideline-directed medical therapy implementation during hospitalization for cardiogenic shock

AIMS

Despite significant morbidity and mortality, recent advances in cardiogenic shock (CS) management have been associated with increased survival. However, little is known regarding the management of patients who survive CS with heart failure (HF) with reduced left ventricular ejection fraction (LVEF, HFrEF), and the utilization of guideline-directed medical therapy (GDMT) in these patients has not been well described. To fill this gap, we investigated the use of GDMT during an admission for CS and short-term outcomes using the Inova single-centre shock registry.

METHODS

We investigated the implementation of GDMT for patients who survived an admission for CS with HFrEF using data from our single-centre shock registry from January 2017 to December 2019. Baseline characteristics, discharge clinical status, data on GDMT utilization and 30 day, 6 month and 12 month patient outcomes were collected by retrospective chart review.

RESULTS

Among 520 patients hospitalized for CS during the study period, 185 (35.6%) had HFrEF upon survival to discharge. The median age was 64 years [interquartile range (IQR) 56, 70], 72% (n = 133) were male, 22% (n = 40) were Black and 7% (n = 12) were Hispanic. Forty-one per cent of patients (n = 76) presented with shock related to acute myocardial infarction (AMI), while 59% (n = 109) had HF-related CS (HF-CS). The median length of hospital stay was 12 days (IQR 7, 18). At discharge, the proportions of patients on beta-blockers, angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs)/angiotensin receptor/neprilysin inhibitors (ARNIs) and mineralocorticoid receptor antagonists (MRAs) were 78% (n = 144), 58% (n = 107) and 55% (n = 101), respectively. Utilization of three-drug GDMT was 33.0% (n = 61). Ten per cent of CS survivors with HFrEF (n = 19) were not prescribed any component of GDMT at discharge. Multivariable logistic regression adjusted for baseline GDMT use revealed that patients with lower LVEF and those who transferred to our centre from an outside hospital were more likely to experience GDMT addition (P < 0.05). Patients prescribed at least one additional class of GDMT during admission had higher odds of 6 month and 1 year survival (P < 0.01): On average, 6 month survival odds were 7.1 times greater [confidence interval (CI) 1.9, 28.5] and 1 year survival odds were 6.0 times greater than those who did not have at least one GDMT added (CI 1.9, 20.5).

CONCLUSIONS

Most patients who survived CS admission with HFrEF in this single-centre CS registry were not prescribed all classes or goal doses of GDMT at hospital discharge. These findings highlight an urgent need to augment multidisciplinary efforts to enhance the post-discharge medical management and outcomes of patients who survive CS with HFrEF.

The Canadian Heart Failure (CAN-HF) Registry: A Canadian Multicentre, Retrospective Study of Outpatients with Heart Failure

Background

Guideline-directed medical therapy (GDMT) reduces events in patients with heart failure (HF) with reduced ejection fraction (HFrEF). Despite this impact, underutilization of GDMT persists. This report sought to describe HF management in Canadian outpatients treated at specialized HF clinics (HFCs).

Methods

The Canadian Heart Failure (CAN-HF) study was retrospective and observational, and it included 1775 patients from 6 Canadian outpatient HFCs, from the period January 2017-April 2020.

Results

We observed improvement in prescription rates in patients with HFrEF, between their first visit and their most-recent clinic visit, across all GDMT classes, in those who were followed at the HFC for ≥ 6 months. The largest prescription rate increases were observed for angiotensin receptor-neprilysin inhibitors and mineralocorticoid-receptor antagonists. However, more than half of the patients remained on angiotensin-converting enzyme inhibitors and/or angiotensin-receptor blockers, despite being symptomatic, according to their New York Heart Association class. Most patients (50%) were on triple therapy, as of their most-recent visit, with fewer (36%) on dual therapy, monotherapy (13%), or no GDMT (2%). Our data also suggest that patients who had been managed at the HFC for > 6 months had higher prescription rates of GDMT and were on higher doses of GDMT, compared to those who were new to the clinic. For patients with HF with preserved ejection fraction, few patients were on candesartan and less than half were on a mineralocorticoid-receptor antagonist.

Conclusions

Our data from HFCs that in most cases were affiliated with academic centres compare favourably with data from other analyses of ambulatory patients with HFrEF, evidence that supports the use of a specialized patient-care model.

Effects of Implementing a Heart Failure Order Set to Optimize Guideline-Directed Medical Therapy and Diuresis in Patients with Acute Heart Failure

Background: Utilization of guideline-directed medical therapy in patients hospitalized for acute heart failure is suboptimal during the hospitalization and after discharge. An inpatient heart failure order set may be a convenient and useful intervention to improve heart failure therapy in the inpatient setting. Methods: This is a retrospective study that assessed the use of an inpatient heart failure order set on pharmacologic therapy in patients hospitalized for acute heart failure from May to August 2022. Patients with heart failure with an ejection fraction less than 50% were included in the analysis. The co-primary endpoints were maintenance or optimization of guideline-directed medical therapy during the hospitalization. Results: Maintenance of guideline-directed medical therapy was significantly greater when providers used the heart failure order set (OR 2.35, 95% CI 1.03-5.33, P = .041). Optimization of guideline-directed medical therapy was also statistically greater with use of the order set (OR 11.31, 95% CI 4.37-29.31, P < .001). Conclusions: An inpatient heart failure order set may be an effective strategy to improve heart failure pharmacotherapy in patients hospitalized with acute heart failure.

An Innovative Patient-Centred Approach to Heart Failure Management: The Best Care Heart Failure Integrated Disease-Management Program

Background

The management of heart failure (HF) is challenging because of the complexities in recommended therapies. Integrated disease management (IDM) is an effective model, promoting guideline-directed care, but the impact of IDM in the community setting requires further evaluation.

Methods

A retrospective evaluation of community-based IDM. Patient characteristics were described, and outcomes using a pre- and post-intervention design were HF-related health-service use, quality of life, and concordance with guideline-directed medical therapy (GDMT).

Results

715 patients were treated in the program (2016 to 2023), 219 in a community specialist-care clinic, and 496 in 25 primary-care clinics. The overall cohort was predominantly male (60%), with a mean age of 73.5 years (± 10.7), and 60% with HF with reduced ejection fraction. In patients with ≥ 6 months of follow-up (n = 267), pre vs post annualized rates of HF-related acute health-service use decreased from 36.3 to 8.5 hospitalizations per 100 patients per year, P < 0.0001, from 31.8 to 13.1 emergency department visits per 100 patients per year, P < 0.0001, and from 152.8 to 110.0 urgent physician visits per 100 patients per year, P = 0.0001. The level of concordance with GDMT improved; the number of patients receiving triple therapy and quadruple therapy increased by 10.1% (95% confidence interval [CI], 2.4%,17.8%) and 19.6% (95% CI, 12.0%, 27.3%), respectively. Within these groups, optimal dosing was achieved in 42.5% (95% CI, 32.0%, 53.6%) and 35.0% (95% CI, 23.1%, 48.4%), respectively. In patients with at least one follow-up visit (n = 286), > 50% experienced a clinically relevant improvement in their quality of life.

Conclusions

A community-based IDM program for HF, may reduce HF-related acute health-service use, improve quality of life and level of concordance with GDMT. These encouraging preliminary outcomes from a real-world program evaluation require confirmation in a randomized controlled trial.

How to tackle therapeutic inertia in heart failure with reduced ejection fraction. A scientific statement of the Heart Failure Association of the ESC

Guideline-directed medical therapy (GDMT) in patients with heart failure and reduced ejection fraction (HFrEF) reduces morbidity and mortality, but its implementation is often poor in daily clinical practice. Barriers to implementation include clinical and organizational factors that might contribute to clinical inertia, i.e. avoidance/delay of recommended treatment initiation/optimization. The spectrum of strategies that might be applied to foster GDMT implementation is wide, and involves the organizational set-up of heart failure care pathways, tailored drug initiation/optimization strategies increasing the chance of successful implementation, digital tools/telehealth interventions, educational activities and strategies targeting patient/physician awareness, and use of quality registries. This scientific statement by the Heart Failure Association of the ESC provides an overview of the current state of GDMT implementation in HFrEF, clinical and organizational barriers to implementation, and aims at suggesting a comprehensive framework on how to overcome clinical inertia and ultimately improve implementation of GDMT in HFrEF based on up-to-date evidence.

Optimization of GDMT for patients with heart failure and reduced ejection fraction: can physiological and biological barriers explain the gaps in adherence to heart failure guidelines?

Heart failure is a growing epidemic with high mortality rates and recurrent hospital admissions that creates a burden on affected individuals, their caregivers and the whole healthcare system. Throughout the years, many randomized trials have established the effectiveness of several pharmacological therapies and electrophysiological devices to reduce hospitalizations and improve quality of life and survival, mostly for patients with heart failure with reduced ejection fraction (HFrEF). These studies led to the publication of national societies' recommendations to guide clinicians in the management of HFrEF. Yet, many reports have shown significant care gaps in adherence to these recommendations in clinical practice, highlighting suboptimal use and/or dosing of evidence-based therapies. Adherence to guidelines has been shown to be associated with the best prognosis in HFrEF, with patients presenting with intolerances or contraindications having the highest risk of events; however, it remains unclear whether this association is causal or merely a marker of more advanced disease. Furthermore, individual characteristics may limit the possibility of reaching the targeted dosage of specific agents. Herein, we provide a comprehensive overview of clinicians' adherence to heart failure guidelines in a specialized real-life setting, particularly regarding use and optimization of guideline-derived medical therapies, as well as the implementation of more recent agents such as sacubitril/valsartan and SGLT2 inhibitors. We seek potential explanations for suboptimal treatment and its impact on patient outcomes.

Electronic health record alerts for management of heart failure with reduced ejection fraction in hospitalized patients: the PROMPT-AHF trial

BACKGROUND AND AIMS

Patients hospitalized for acute heart failure (AHF) continue to be discharged on an inadequate number of guideline-directed medical therapies (GDMT) despite evidence that inpatient initiation is beneficial. This study aimed to examine whether a tailored electronic health record (EHR) alert increased rates of GDMT prescription at discharge in eligible patients hospitalized for AHF.

METHODS

Pragmatic trial of messaging to providers about treatment of acute heart failure (PROMPT-AHF) was a pragmatic, multicenter, EHR-based, and randomized clinical trial. Patients were automatically enrolled 48 h after admission if they met pre-specified criteria for an AHF hospitalization. Providers of patients in the intervention arm received an alert during order entry with relevant patient characteristics along with individualized GDMT recommendations with links to an order set. The primary outcome was an increase in the number of GDMT prescriptions at discharge.

RESULTS

Thousand and twelve patients were enrolled between May 2021 and November 2022. The median age was 74 years; 26% were female, and 24% were Black. At the time of the alert, 85% of patients were on β-blockers, 55% on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, 20% on mineralocorticoid receptor antagonist (MRA) and 17% on sodium-glucose cotransporter 2 inhibitor. The primary outcome occurred in 34% of both the alert and no alert groups [adjusted risk ratio (RR): 0.95 (0.81, 1.12), P = .99]. Patients randomized to the alert arm were more likely to have an increase in MRA [adjusted RR: 1.54 (1.10, 2.16), P = .01]. At the time of discharge, 11.2% of patients were on all four pillars of GDMT.

CONCLUSIONS

A real-time, targeted, and tailored EHR-based alert system for AHF did not lead to a higher number of overall GDMT prescriptions at discharge. Further refinement and improvement of such alerts and changes to clinician incentives are needed to overcome barriers to the implementation of GDMT during hospitalizations for AHF. GDMT remains suboptimal in this setting, with only one in nine patients being discharged on a comprehensive evidence-based regimen for heart failure.

Access to Heart Failure Services in Canada: Findings of the Heart and Stroke National Heart Failure Resources and Services Inventory

BACKGROUND

The rising incidence of heart failure (HF) in Canada necessitates commensurate resources dedicated to its management. Several health system partners launched an HF Action Plan to understand the current state of HF care in Canada and address inequities in access and resources.

METHODS

A national Heart Failure Resources and Services Inventory (HF-RaSI) was conducted from 2020 to 2021 of all 629 acute care hospitals and 20 urgent care centres in Canada. The HF-RaSI consisted of 44 questions on available resources, service,s and processes across acute care hospitals and related ambulatory settings.

RESULTS

HF-RaSIs were completed by 501 acute care hospitals and urgent care centres, representing 94.7% of all HF hospitalisations across Canada. Only 12.2% of HF care was provided by hospitals with HF expertise and resources, and 50.9% of HF admissions were in centres with minimal outpatient or inpatient HF capabilities. Across all Canadian hospitals, 28.7% did not have access to B-type natriuretic peptide testing, and only 48.1% had access to on-site echocardiography. Designated HF medical directors were present at 21.6% of sites (108), and 16.2% sites (81) had dedicated inpatient interdisciplinary HF teams. Among all of the sites, 28.1% (141) were HF clinics, and of those, 40.4% (57) had average wait times from referral to first appointment of more than 2 weeks.

CONCLUSIONS

Significant gaps and geographic variation in delivery and access to HF services exist in Canada. This study highlights the need for provincial and national health systems changes and quality improvement initiatives to ensure equitable access to the appropriate evidence-based HF care.

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

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.