Despite guidelines and quality improvement efforts, many people with heart failure with reduced ejection fraction (HFrEF) aren’t prescribed the recommended medications. And among those who are, fewer than one-fourth receive optimal doses, according to a registry analysis of ambulatory patients.
“Despite proven benefits and strong guideline recommendations, medication use and dosing in routine clinical practice have traditionally fallen short of levels achieved in clinical trials,” wrote lead author Stephen J. Greene, MD, with Duke Clinical Research Institute, and colleagues in the Journal of the American College of Cardiology. “As rates of mortality and morbidity for the general HFrEF population remain high, improving real-world use of proven medications remains a critically important quality improvement initiative.”
The authors studied 3,518 patients with stable, chronic heart failure from 150 primary care and cardiology practices as part of the CHAMP-HF registry. Patients were 66 years old on average and 71 percent male, and their mean ejection fraction was 29 percent.
Greene et al. evaluated prescription rates and dosing amounts for the following medications: angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor neprilysin inhibitor (ARNI), beta-blocker and mineralocorticoid receptor antagonist (MRA). Notably, most patients had no documented contraindication to the medications, with the highest rate being 1.8 percent for ACEI/ARB/ARNI.
The researchers made the following conclusions:
- Only 1 percent of patients received guideline-recommended doses of all classes of medications.
- Among eligible patients, 27 percent weren’t prescribed ACEI/ARB/ARNI, 33 percent weren’t prescribed a beta-blocker and 67 percent weren’t on MRA therapy.
- For patients taking the medications, guideline-recommended doses were rare for ACEI/ARB (17 percent), ARNI (14 percent) and beta-blockers (28 percent), but 77 percent for MRA.
- In general, older patients and those with lower blood pressure, worse functional status and more recent heart failure hospitalizations were less likely to receive guideline-directed medical therapy (GDMT).
“These findings are compatible with the previously described ‘risk-treatment paradox,’ where HF patients with greatest need are less likely to receive appropriate therapy,” Greene et al. wrote.
“It is conceivable that GDMT underuse and underdosing in higher risk patients may be driven by disproportionate emphasis among providers on potential patient destabilization with medication changes rather than clinical benefits of therapy. Although clinical judgment remains paramount, randomized evidence supports the relative safety of higher doses of GDMT as compared with lower doses.”
The researchers acknowledged there was no way to determine whether underdosing was an oversight or whether previous titration to target levels had been attempted but not well tolerated by the patient. Also, contraindications to medications may have existed without documentation.
In an accompanying editorial, two cardiologists said the study is a lesson in clinical inertia. The low adherence to target doses among HFrEF patients was remarkably similar to another registry analysis (IMPROVE HF) published in 2010.
“Just as matter will remain at rest or continue in uniform motion in the same straight line unless acted upon by some external force, the morbidity and mortality associated with HFrEF will not improve unless patients are optimized by GDMT,” wrote John L. Jefferies, MD, MPH, and Nasrien E. Ibrahim, MD.
The editorialists note the reasons for low adherence to GDMT are likely multifactorial. Clinicians may be reluctant to try new therapies if a patient is “doing fine,” they said, just as a patient may oppose changing a regimen. Hurdles imposed on new therapies by insurance companies and a lack of staff to monitor and care for the growing population of HF patients also contributes to nonadherence.
Ibrahim and Jefferies recommended institutional task forces tackle this problem and said patients should be their own advocates.
“If patients understood the guidelines, if they knew the survival and quality-of-life benefits they could attain from adhering to GDMT, the uptake of such therapies would improve. … Just as stop signs are not merely suggestions for drivers at intersections, neither are published guidelines for clinicians managing HF patients,” they wrote.
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.