Long-term maintenance of guideline-directed medical therapy and its prognostic impact in a community-based heart failure unit
M Ferre-Vallverdu, E Amao, B Carbonell, C Ligero, A Sero, A Mendela, R Sanchez, O Palazon, H Tajes, A El Amrani, P Cueto, G Vives, J Servello, P ValdovinosAbstract
Abstract
Despite robust evidence supporting guideline-directed medical therapy (GDMT) in heart failure, sustaining these treatments over time remains a major unmet clinical need. In real-world practice, drug discontinuation and dose reductions are frequent and may compromise the prognostic benefits observed in clinical trials. However, the extent and clinical impact of GDMT withdrawal in routine care are poorly characterized.
We aimed to quantify the rate of GDMT reduction or discontinuation and to evaluate its association with outcomes in a community-based Heart Failure Unit.
Methods
We studied consecutive patients with heart failure with reduced ejection fraction followed in our Heart Failure Unit between January 2021 and December 2025. Treatment maintenance was evaluated between 6 months after therapy optimization and the last follow-up visit. Patients were classified into a decrease group (dose reduction or discontinuation) or a maintenance group (treatment maintained, increased, or newly initiated).
Results
Among 473 patients (median follow-up 518 ± 458 days), 50 (11%) reduced beta-blockers, 37 (8%) ACEi/ARB/ARNI, 33 (8%) mineralocorticoid receptor antagonists, and 10 (2%) SGLT2 inhibitors. Patients in the beta-blocker decrease group had worse renal function (Creat 1.49 ± 0.89 vs 1.17 ± 0.59mg/dL, p=0.03) and higher LVEF at last visit (50 ± 9 vs 44 ± 13; p=0.006), while NT-proBNP levels were consistently higher across all decrease groups.
Treatment reduction was strongly associated with excess mortality: beta-blocker decrease 10 (20%) vs 22 (5%); p<0.0001, ACEi/ARB/ARNI decrease 7 (19%) vs 24 (5.9%); p= 0.002, ARM decrease: 9 (28%) vs 21 (5.4%); p<0.0001.
Conclusions
In routine clinical practice, approximately one in ten patients requires dose reduction or discontinuation of foundational heart failure therapies. These changes are associated with a striking increase in mortality, underscoring that maintaining GDMT over time is not only difficult but critical for patient survival.For image description, please refer to the figure legend and surrounding text.