Guideline-directed medical therapy across neighbourhood socioeconomic deprivation in patients with heart failure with reduced ejection fraction: data from the Swedish Heart Failure Registry

Introduction

Neighbourhood socioeconomic deprivation, defined as the lack of economic, social, and physical resources within a geographic area, has been linked to morbidity and mortality in patients with HFrEF. It is unclear whether this link is explained by disparities in use of guideline-directed medical therapy (GDMT).

Purpose

To evaluate, in patients with HFrEF, the associations between neighbourhood socioeconomic deprivation and (1) use of GDMT and (2) risks of all-cause death, cardiovascular (CV) death and HF hospitalisation (HFH), and to determine the extent to which GDMT mediates these relationships.

Methods

We included patients with HFrEF enrolled in the Swedish HF Registry between 2011-2023. Neighbourhood socioeconomic deprivation was graded according to the place of residence using the Care Need Index (CNI), an area-level measure of socioeconomic conditions, categorised into quintiles (Q1 least; Q5 most disadvantaged). GDMT was defined as use of all the pharmacological treatments with class I recommendations according to the ESC guidelines during the study period: ACEi/ARB or ARNI(from 2016), beta-blockers, MRA, and SGLT2i(from 2021). Independent associations between CNI quintiles and GDMT use were evaluated using multivariable logistic regression. Multivariable Cox proportional hazards regression models were fitted to estimate associations between CNI quintiles and risks of all-cause death, CV death, and HFH. Mediation analyses were conducted to estimate the extent to which GDMT mediated differences in outcomes across CNI quintiles. All models were adjusted for age, sex, comorbidities, clinical severity, and socioeconomic factors.

Results

Of 50,782 patients with HFrEF (median age 73 years, 71% males), 39% received all recommended GDMTs. Patients living in the most socioeconomically deprived neighbourhoods (Q4 and Q5) were younger, had lower income and education, a higher burden of comorbidities, and more severe HF, as compared with those living in the least deprived neighbourhoods (Q1). Residence in the most deprived areas (Q4 and Q5) vs. the least (Q1) was associated with lower adjusted odds of receiving GDMT (OR 0.91 and 0.93, respectively, Figure 1). Over a median follow-up of 2.1 years (IQR 0.6–5.0), with Q1 (least deprived) as a reference, Q5 was associated with a 6% higher risk of CV mortality and an 11% higher risk of HFH. For all-cause mortality, risks were 6% higher in Q4 and 9% higher in Q5 (Figure 2). GDMT mediated only ≈1–2% of mortality differences and showed a negligible effect for HFH.

Conclusions

Neighbourhood socioeconomic deprivation was associated with lower GDMT use and higher risks of mortality and HFH in patients with HFrEF. Disparities in GDMT use according to the degree of neighbourhood socioeconomic deprivation explained only a small proportion of these differences in outcomes, suggesting that strategies beyond pharmacotherapy implementation are needed to reduce inequities in HF outcomes.

For image description, please refer to the figure legend and surrounding text. Figure 2 For image description, please refer to the figure legend and surrounding text.