Durham, NC—Recommendations to adjust guideline-directed medical therapy (GDMT) are not followed often enough in patients with heart failure and reduced ejection factor (HFrEF), according to a new conference presentation.

The Duke University Health System–led study pointed out that initiation of GDMT and titration to the highest tolerated dose is recommended to reduce morbidity and mortality in patients with HFrEF, defined as left ventricular ejection fraction <40%. The presentation planned for the American College of Cardiology’s Annual Scientific Session Together With World Congress of Cardiology in New Orleans from March 4 to March 6 discussed patterns of adjustment of GDMT 1 year post–heart failure (HF) hospitalization.

CONNECT-HF was a cluster-randomized trial that targeted postdischarge quality improvement for patients with HFrEF. The researchers used data from 4,646 patients enrolled at 150 United States sites between 2017 and 2020 to assess patterns of postdischarge medication changes during follow-up.

The results indicated that overall adjustments—either escalation or de-escalation—for the entire cohort were infrequent. Those included:

• Beta-blockers (55%)
• Angiotensin-converting enzyme inhibitors (ACEi)/angiotensin-receptor blockers (ARBs; 42%)
• Angiotensin receptor neprilysin inhibitors (ARNIs; 23%)
• Mineralocorticoid receptor antagonists (MRAs; 33%)
• Sodium-glucose cotransporter 2 inhibitors (SGLT2i; 2%).

“Compared to patients with known HFrEF, patients with new HFrEF had more frequent intensification of ACEi/ARB (26% vs. 21%) and ARNI (22% vs. 17%) as well as addition of SGLT2i (3% vs. 1%),” the authors advised. “Rates of escalation of beta-blocker (36% vs. 35%) and MRA (20% vs. 19%) were similar between groups.”

They added that, by the end of 1 year, few patients were on GDMT at target dosages—beta blockers (30%), ACEi/ARB (16%), ARNI (11%), MRA (36%), and SGLT2i (2%).

“Changes to GDMT in the year following a hospitalization for HFrEF were infrequent even among patients with a new diagnosis of HFrEF,” the study concluded. “As such, clinicians should take advantage of all opportunities to intensify GDMT.”

Meanwhile, a meta-analysis from Creighton University in Omaha, Nebraska, and the Mayo Clinic in Rochester, Minnesota, found that SGLT2i reduce the combined risk of HF hospitalization or cardiovascular mortality among HF patients with LVEF >40% in some, but not all, cases.

“However, younger patients, racial minorities, and patients from Asia did not demonstrate such a reduction,” according to their presentation at the conference. “Further research is necessary to identify the reasons for such disparities.”

Those conclusions were based on a meta-analysis of six trials with 15,989 patients. “Patients <65 years old, from racial minorities, or from Asia receiving SGLT2i did not demonstrate a significant reduction in primary composite outcome,” the authors reported.

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