Opportunities and Achievement of Medication Initiation Among Inpatients With Heart Failure With Reduced Ejection Fraction

Digital Solutions for the Optimization of Pharmacologic Therapy for Heart Failure

Data from large-scale, randomized, controlled trials demonstrate that contemporary treatments for heart failure (HF) can substantially improve morbidity and mortality. Despite this, observed outcomes for patients living with HF are poor, and they have not improved over time. The are many potential reasons for this important problem, but inadequate use of optimal medical therapy for patients with HF, an important component of guideline-directed medical therapy, in routine practice is a principal and modifiable contributor. In this state-of-the-art review, we focus on digital interventions that specifically target the rapid initiation and titration of medical therapy for HF, typically not involving face-to-face encounters. Early data suggest that digital interventions that use data collected outside of structured episodes of care can facilitate initiation and titration of guideline-directed medical therapy for patients with HF. More data are necessary, however, to understand the safety and efficacy of these interventions compared with current care models. In addition, specific efforts by key constituents are necessary to generate sufficient data on the effectiveness and sustainability of digital interventions in routine practice and to ensure that they do not exacerbate existing disparities in care.

Multiregional Implementation Initiative's Impact on Guideline-Based Performance Measures for Patients Hospitalized With Heart Failure: IMPLEMENT-HF

BACKGROUND

Despite randomized data for survival benefit (with class 1 recommendations) for treating heart failure (HF) with reduced ejection fraction using quadruple medical therapy (QMT)-defined as evidence-based β-blockers, sodium-glucose cotransporter 2 inhibitor, preferably angiotensin receptor/neprilysin inhibitor, and mineralocorticoid receptor antagonist-it is underutilized. IMPLEMENT-HF is a multiregional HF quality improvement initiative to improve care and outcomes for patients with HF by enhancing the use of QMT in routine practice.

METHODS

This analysis of HF with reduced ejection fraction treatment in patients from hospitals participating in the American Heart Association's Get With The Guidelines-HF who volunteered to participate in IMPLEMENT-HF in 7 US regions. IMPLEMENT-HF included multidisciplinary learning to share strategies for formulary changes, electronic health record tools, and patient resources with site-level feedback reports. Participants gathered QMT data at discharge and 30 days after discharge. We evaluated QMT utilization and variation, in addition to other prespecified performance measures, from Q1 2021 to Q2 2023.

RESULTS

The median (interquartile range) age of 43 558 admitted patients at 61 hospitals was 74 (63-83) years; 16 530 (38%) belonged to racial and ethnic minorities, and 22 228 (51%) were women. Between Q1 2021 and Q2 2023, defect-free QMT improved from 4.7% to 44.6% at discharge and from 0% to 44.8% at 30 days (both P<0.0001). There was also substantially improved incorporation of health-related social needs assessments. The magnitude of improvements was similar when stratified by sex or race and ethnicity, yet there was significant regional variation.

CONCLUSIONS

Among healthcare systems participating in IMPLEMENT-HF, there was a marked increase in QMT use among eligible patients over the course of the initiative. This quality improvement initiative supports a learning collaborative model to promote improvements in QMT use.

A Digital Platform to Optimize Guideline Directed Heart Failure Therapy: Rationale and Design of the AIM-POWER Trial

BACKGROUND

Patients with heart failure (HF) remain at high risk for hospitalization and death in part due to underutilization of available HF pharmacologic therapy. Digital interventions may facilitate rapid initiation and titration of HF pharmacologic therapy but have not been systematically evaluated in adequately powered randomized control trials. In the AIM-POWER study, we evaluated the safety and efficacy of the BiovitalsHF DTx decision support platform as a strategy to guide optimal initiation and titration of pharmacologic therapy in patients with HF with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

We enrolled 122 participants with symptomatic HFrEF (left ventricular ejection fraction≤40%) who were not yet optimized on HF pharmacologic therapy. Participants were randomized 1:1 in an open-label fashion to management supported with BiovitalsHF or usual care. Using wearable home-based monitors and digital scales, the BiovitalsHF platform assembled data regarding patient status and formulated suggestions regarding initiation and titration of HF pharmacologic therapy as per published guidelines. These recommendations were provided to site clinicians, but final decisions on prescribing and titration were left to the sites. The primary outcome was the between-group difference in the change from baseline in a HF optimal medical therapy score from baseline to 90 days.

CONCLUSION

The results of the AIM-POWER study will provide important insights on digital interventions for HF management and evaluate the effectiveness of BiovitalsHF to improve the use and dosing of pharmacologic therapy for participants with HFrEF.

Delay in cardiology consultation after primary care physician referrals in heart failure: Clinical implications

AIMS

To investigate the association between the elapsed time to cardiology care following a primary care physician (PCP) referral and 1 year outcomes among patients with heart failure (HF).

METHODS

Data from electronic medical records at our institution encompassing all PCP referrals to cardiology consultation from 2010 to 2021 (N = 68 518) were analysed. Of these, 6379 patients had a prior diagnosis of HF. Using a Cox regression model for hospitalization and mortality outcomes, the association between delay time in cardiology care post-PCP referral and 1 year outcomes was examined, adjusting for age, gender and comorbidities.

RESULTS

A significant increase in 1 year mortality rates with delayed cardiology care was observed for each day: all-cause (0.25%), cardiovascular (CV) (0.13%) and HF (0.11%). In multivariate analysis, continuous delay to consultation was independently associated with higher risk of all-cause [hazard ratio (HR): 1.02; 95% confidence interval (CI) (1.01-1.02); P < 0.01], CV [1.01 (1.00-1.02); P < 0.01] and HF mortality (HR: 1.01; 95% CI 1.00-1.03; P < 0.01). Patients attended in the 25th quartile of time delay (<2 days) had significantly lower mortality and HF readmission rates [1.21 (1.10-1.33); P < 0.01] as compared with patients in the 75th quartile (>14 days).

CONCLUSIONS

Delay in cardiology assistance following a PCP referral among patients previously diagnosed with HF was associated with increased in all-cause, CV, and HF mortality at 1 year.

Hospital Heart Failure Medical Therapy Score and Associated Clinical Outcomes and Costs

Importance

A composite score for guideline-directed medical therapy (GDMT) for patients with heart failure (HF) is associated with increased survival. Whether hospital performance according to a GDMT score is associated with a broader array of clinical outcomes at lower costs is unknown.

Objectives

To evaluate hospital variability in GDMT score at discharge, 90-day risk-standardized clinical outcomes and costs, and associations between hospital GDMT score and clinical outcomes and costs.

Design, Setting, and Participants

This was a retrospective cohort study conducted from January 2015 to September 2019. Included for analysis were patients hospitalized for HF with reduced ejection fraction (HFrEF) in the Get With the Guidelines-Heart Failure Registry, a national hospital-based quality improvement registry. Study data were analyzed from July 2022 to April 2023.

Exposures

GDMT score at discharge.

Main Outcomes and Measures

Hospital variability in GDMT score, a weighted index from 0 to 1 of GDMT prescribed divided by the number of medications eligible, at discharge was evaluated using a generalized linear mixed model using the hospital as a random effect and quantified with the adjusted median odds ratio (AMOR). Parallel analyses centering on 90-day mortality, HF rehospitalization, mortality or HF rehospitalization, home time, and costs were performed. Costs were assessed from the perspective of the Centers of Medicare & Medicaid Services. Associations between hospital GDMT score and clinical outcomes and costs were evaluated using Spearman coefficients.

Results

Among 41 161 patients (median [IQR] age, 78 [71-85] years; 25 546 male [62.1%]) across 360 hospitals, there was significant hospital variability in GDMT score at discharge (AMOR, 1.23; 95% CI, 1.21-1.26), clinical outcomes (mortality AMOR, 1.17; 95% CI, 1.14-1.24; HF rehospitalization AMOR, 1.22; 95% CI, 1.18-1.27; mortality or HF rehospitalization AMOR, 1.21; 95% CI, 1.18-1.26; home time AMOR, 1.07; 95% CI, 1.06-1.10) and costs (AMOR, 1.23; 95% CI, 1.21-1.26). Higher hospital GDMT score was associated with lower hospital mortality (Spearman ρ, -0.22; 95% CI, -0.32 to -0.12; P < .001), lower mortality or HF rehospitalization (Spearman ρ, -0.17; 95% CI, -0.26 to -0.06; P = .002), more home time (Spearman ρ, 0.14; 95% CI, 0.03-0.24; P = .01), and lower cost (Spearman ρ, -0.11; 95% CI, -0.21 to 0; P = .047) but not with HF rehospitalization (Spearman ρ, -0.10; 95% CI, -0.20 to 0; P = .06).

Conclusions and Relevance

Results of this cohort study reveal that hospital variability in GDMT score, clinical outcomes, and costs was significant. Higher GDMT score at discharge was associated with lower mortality, lower mortality or hospitalization, more home time, and lower cost. Efforts to increase health care value should include GDMT optimization.

Digital solutions to optimize guideline-directed medical therapy prescription rates in patients with heart failure: a clinical consensus statement from the ESC Working Group on e-Cardiology, the Heart Failure Association of the European Society of Cardiology, the Association of Cardiovascular Nursing & Allied Professions of the European Society of Cardiology, the ESC Digital Health Committee, the ESC Council of Cardio-Oncology, and the ESC Patient Forum

The 2021 European Society of Cardiology guideline on diagnosis and treatment of acute and chronic heart failure (HF) and the 2023 Focused Update include recommendations on the pharmacotherapy for patients with New York Heart Association (NYHA) class II-IV HF with reduced ejection fraction. However, multinational data from the EVOLUTION HF study found substantial prescribing inertia of guideline-directed medical therapy (GDMT) in clinical practice. The cause was multifactorial and included limitations in organizational resources. Digital solutions like digital consultation, digital remote monitoring, digital interrogation of cardiac implantable electronic devices, clinical decision support systems, and multifaceted interventions are increasingly available worldwide. The objectives of this Clinical Consensus Statement are to provide (i) examples of digital solutions that can aid the optimization of prescription of GDMT, (ii) evidence-based insights on the optimization of prescription of GDMT using digital solutions, (iii) current evidence gaps and implementation barriers that limit the adoption of digital solutions in clinical practice, and (iv) critically discuss strategies to achieve equality of access, with reference to patient subgroups. Embracing digital solutions through the use of digital consults and digital remote monitoring will future-proof, for example alerts to clinicians, informing them of patients on suboptimal GDMT. Researchers should consider employing multifaceted digital solutions to optimize effectiveness and use study designs that fit the unique sociotechnical aspects of digital solutions. Artificial intelligence solutions can handle larger data sets and relieve medical professionals' workloads, but as the data on the use of artificial intelligence in HF are limited, further investigation is warranted.

Ischemic Stroke and Reduced Left Ventricular Ejection Fraction: A Multidisciplinary Approach to Optimize Brain and Cardiac Health

Reduced left ventricular ejection fraction ≤40%, a known risk factor for adverse cardiac outcomes and recurrent acute ischemic stroke, may be detected during an acute ischemic stroke hospitalization. A multidisciplinary care paradigm informed by neurology and cardiology expertise may facilitate the timely implementation of an array of proven heart failure-specific therapies and procedures in a nuanced manner to optimize brain and cardiac health.

The effect of kidney function on guideline-directed medical therapy implementation and prognosis in heart failure with reduced ejection fraction

BACKGROUND

Kidney dysfunction (KD) is a main limiting factor of applying guideline-directed medical therapy (GDMT) and reaching the recommended target doses (TD) in heart failure (HF) with reduced ejection fraction (HFrEF).

HYPOTHESIS

We aimed to assess the success of optimization, long-term applicability, and adherence of neurohormonal antagonist triple therapy (TT:RASi [ACEi/ARB/ARNI] + βB + MRA) according to the KD after a HF hospitalization and to investigate its impact on prognosis.

METHODS

The data of 247 real-world, consecutive patients were analyzed who were hospitalized in 2019-2021 for HFrEF and then were followed-up for 1 year. The application and the ratio of reached TD of TT at hospital discharge and at 1 year were assessed comparing KD categories (eGFR: ≥90, 60-89, 45-59, 30-44, <30 mL/min/1.73 m2 ). Moreover, 1-year all-cause mortality and rehospitalization rates in KD subgroups were investigated.

RESULTS

Majority of the patients received TT at hospital discharge (77%) and at 1 year (73%). More severe KD led to a lower application ratio (p < .05) of TT (92%, 88%, 80%, 73%, 31%) at discharge and at 1 year (81%, 76%, 76%, 68%, 40%). Patients with more severe KD were less likely (p < .05) to receive TD of MRA (81%, 68%, 78%, 61%, 52%) at discharge and a RASi (53%, 49%, 45%, 21%, 27%) at 1 year. One-year all-cause mortality (14%, 15%, 16%, 33%, 48%, p < .001), the ratio of all-cause rehospitalizations (30%, 35%, 40%, 43%, 52%, p = .028), and rehospitalizations for HF (8%, 13%, 18%, 20%, 38%, p = .001) were significantly higher in more severe KD categories.

CONCLUSIONS

KD unfavorably affects the application of TT in HFrEF, however poorer mortality and rehospitalization rates among them highlight the role of the conscious implementation and up-titration of GDMT.