Frailty is associated with suboptimal guideline-directed medical therapy in heart failure hospital admissions

Background

Frailty is increasingly recognised as a critical factor influencing clinical outcomes in patients with heart failure (HF). However, despite the benefits of guideline-directed medical therapy (GDMT), adherence to its use in frail populations remains rather unexplored.

Purpose

The aim of the study was to determine the impact of frailty on the prescription of the four pillars of GDMT for HF - renin-angiotensin system (RAS) inhibitors (ARNI, ACEi, ARB), beta-blockers (BB), mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter 2 inhibitors (SGLT2i) - on admission and at discharge in patients hospitalised for acute decompensation of heart failure (ADHF).

Methods

This is a retrospective analysis of data submitted from a single centre to the National HF audit between January and June 2023. Additional frailty and medication data was retrospectively collected from electronic patient health records. Patients were divided into two groups based on the Rockwood Clinical Frailty Scale (1). Patients with a CFS score ≥ 4 at baseline were classified as frail, while those with a score < 4 were considered non-frail. Chi-squared and t-tests were used to compare baseline characteristics and GDMT between frailty groups.

Results

This analysis included 323 patients admitted with ADHF in our centre between 1st January and 22nd June 2023, of whom 70.6% were classified as frail based on the CFS criteria. Frail patients were older, had a lower mean admission haemoglobin, a higher proportion had CKD, and more were female, compared to non-frail counterparts (Figure 1).

At admission no significant difference was observed, so frail patients weren't less frequently prescribed GDMT compared to non-frail patients. Discharge data revealed different trends instead, with frail patients receiving significantly fewer prescriptions for RASi, BB, MRA, and SGLT2i (p<0.001, p=0.006, p<0.001, p=0.003, respectively), as shown in Figure 2C.

Conclusions

Frailty is one of the factors that may withhold GDMT in patients with ADHF. The disparity observed in GDMT prescription between frail and non-frail patients at discharge but not on admission may reflect differences in clinical decision-making during hospitalisation. At admission, medication regimens often reflect prior outpatient management, where frailty is less systematically assessed. During hospitalisation, safety concerns, multimorbidity, and polypharmacy in frail patients may lead clinicians to adopt a more cautious approach, potentially prioritising perceived risks over guideline adherence. Integrating frailty assessment into routine care, along with multidisciplinary strategies and personalised treatment plans, is essential to improve patient management. Further research is warranted to adjust for confounding factors and to explore the clinical outcomes of improved GDMT adherence in this vulnerable patient population.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.