Clinical Impact of Guideline-Directed Medical Therapy in Patients with Left Ventricular Assist Device: An International Multicenter Study
Miloud Cherbi, Clément Delmas, Paul Gautier, Karim Benali, Kerstin Bode, Elena Efimova, Alexey Dashkevich, Jackson Liang, John Larson, Blandine Mondesert, Jacinthe Boulet, Pierre-Emmanuel Noly, François Picard, Jean Luc Pasquié, Jean-Baptiste Gourraud, Sandro Ninni, Laurence Jesel, Alexandre Sebestyen, Marylou Para, Jean-Claude Deharo, Frederic Anselme, Laure Champ-Rigot, Soundous M’Rabet, Bertrand Pierre, Romain Eschalier, Mathieu Echivard, Anne-Céline Martin, Nicolas Lellouche, Matteo Pozzi, Pierre Groussin, Erwan Flecher, Vincent Galand, Raphael MartinsAbstract
Background
While guideline-directed medical therapy (GDMT) is recommended for left ventricular assist device (LVAD) recipients, real-world evidence supporting its clinical impact remains limited. This study evaluated the association between GDMT prescription and clinical outcomes in LVAD patients.
Methods
This international retrospective multicenter study included 875 LVAD patients from 22 centers. Patients were categorized based on the number of GDMT (ACE-I/ARBs, beta-blockers, MRAs) prescribed. Primary outcome was 6-month all-cause mortality. Secondary outcome was late ventricular arrhythmias (VAs) (>30 days post-implant). Multivariable Cox regression and ordinal logistic regression analyses were performed.
Results
Overall, only 261 patients (29.8%) received triple GDMT, while 97 (11.1%) received no GDMT. After multivariable adjustment, the number of prescribed GDMTs was independently associated with improved survival, with aHRs for all-cause mortality of 0.51 (0.33–0.75, p<0.01) for triple therapy, 0.39 (0.26–0.59, p<0.01) for dual therapy, and 0.45 (0.30–0.67, p<0.01) for single therapy, all compared with no GDMT. Similarly, ACE-I/ARB were associated with a lower risk of late VAs (aHR 0.65 [0.50–0.84], p<0.01). Female sex, diabetes, early VAs, and higher bilirubin levels were associated with lower GDMT prescription rates. Major LVEDD improvement (≥10mm reduction) increased progressively from 51.5% without GDMT to 66.1% with triple therapy.
Conclusion
In this large international study, the use of GDMT in LVAD patients was associated with improved survival, with benefits observed even with single-agent therapy. Despite these benefits, only 30% of patients received optimal triple therapy, highlighting the need for improved implementation strategies and standardized protocols in this population.