Longitudinal patterns of guideline-directed medical therapy use in severe heart failure with reduced ejection fraction after hospitalization: insights from the CONNECT-HF trial
P Rambarat, A Giczewska, L A Kaltenbach, B B Granger, G C Fonarow, N M Albert, J Butler, L A Allen, G M Felker, A F Hernandez, A D DevoreAbstract
Background
Few studies have examined longitudinal use of guideline-directed medical therapy (GDMT) in patients with severe heart failure (HF) with reduced left ventricular ejection fraction (LVEF). The Care Optimization Through Patient and Hospital Engagement Clinical Trial for Heart Failure (CONNECT-HF) evaluated the effect of a hospital and post-discharge quality improvement intervention on HF outcomes, including GDMT utilization, and thus provides an opportunity to characterize medical therapy use over time in patients with severe HF.
Purpose
To compare patterns of GDMT use over time post-discharge from a HF hospitalization in patients with severe HF versus those without severe HF in the CONNECT-HF trial.
Methods
Severe HF was defined as participants with all of the following high-risk criteria: ≥ 1 prior HF hospitalization within 12 months, LVEF < 30%, elevated BNP ≥ 300 pg/mL, and Kansas City Cardiomyopathy Questionnaire (KCCQ-12) score < 50. GDMT treatment patterns (not prescribed, persistence [no changes], escalation, deescalation) were assessed at baseline, 3, 6, and 12-months post-discharge. To illustrate the incidence of HF rehospitalization or all-cause death over time, cumulative incidence curves for severe and non-severe HF were generated using time to first event analyses.
Results
Among 3902 patients, 983 (25%) met criteria for severe HF. Patients with severe HF were younger (mean age 60 years versus 63 years), had more atrial arrythmias (43% versus 41%), and lower admission systolic blood pressure (mean 115 mmHg versus 119 mmHg) than those without severe HF. Patients with severe HF had lower LVEF (20±5% versus 28±8%), higher median BNP (2790 pg/mL versus 2001 pg/mL), and more frequent HF hospitalizations in the preceding year (50% had one prior HF hospitalization versus 20%). At discharge, 61% of patients with severe HF received a renin-angiotensin-aldosterone system inhibitor (RAASi), 76% an evidence-based beta-blocker (BB), 39% a mineralocorticoid receptor antagonist (MRA), and 1% a sodium glucose cotransporter 2 (SGLT2) inhibitor (the trial was conducted before SGLT2 inhibitors were widely used for HF management). Over 12 months, GDMT use declined to 40% on a RAASi, 49% on a BB, 26% on an MRA, and 0.5% on an SGLT2i (Figure 1A). Overall, RAASi was deescalated in 20%, BB in 25%, MRA in 15% and SGLT2i in 0.1% of severe HF patients (Figure 1C). Similar trends were observed in patients not meeting all criteria for severe HF (Figure 1, panels B and D). At one year, HF rehospitalization or all-cause death occurred in 48% of patients with severe HF versus 30% of patients without severe HF (Figure 2).
Conclusion
Baseline use of GDMT at hospital discharge was low and decreased over time post-discharge in patients with and without severe HF in the CONNECT-HF trial. The cumulative incidence of adverse outcomes in patients with severe HF was high underscoring the need for additional strategies to reduce risk in this population.GDMT use over 12 months post-dischargeFor image description, please refer to the figure legend and surrounding text.Cumulative incidence of adverse outcomesFor image description, please refer to the figure legend and surrounding text.