Real-world implementation of guideline-directed medical therapy in heart failure across the ejection fraction spectrum: Insights from iCaReMe Global Registry
A Hadaoui, C Pollock, M Arici, C N Huang, R Silva-Tinoco, A A El Sayed, H Vasnawala, K KhuntiAbstract
Background
The use of guideline-directed medical therapy (GDMT) in heart failure (HF) involving quadruple therapy (ACEi/ARB/ARNI, beta-blockers, MRAs, SGLT2i) has been shown to decrease hospitalization and mortality risks. Real-world data on GDMT uptake in diverse HF populations and across the ejection fraction spectrum are limited.
Purpose
To characterize the clinical profiles, GDMT adoption rates among HFrEF, HFmrEF and HFpEF patients from Asia-Pacific (APAC), Latin America (LATAM), and Middle East and Africa (MEA) regions, and identify determinants of quadruple therapy use.
Methods
Cross-sectional observational study using baseline data of adults with HF enrolled in the iCaReMe Global Registry (NCT03549754) across 20 countries in APAC, LATAM and MEA regions between 2020 and 2024. Patients’ characteristics and treatment patterns were summarized descriptively. Logistic regression was used for factors influencing GDMT use.
Results
The study enrolled 3,206 HF participants, 1,917 (59.8%) with HFrEF, 523 (16.3%) with HFmrEF, and 766 (23.9%) with HFpEF. The mean age was 59.2 years, and 61.1% were males. Overall, mean LVEF was 40.0 %, and mean HF duration was 3.1 years. Comorbidities included hypertension (HTN; 60.8%), type 2 diabetes mellitus (T2DM; 56.0%), and chronic kidney disease (CKD; 24.6%). Quadruple therapy was prescribed in 28.6% of patients overall, with higher rates in HFrEF (38.9%) compared to HFmrEF (21.6%) and HFpEF (7.8%). SGLT2i use showed a similar pattern (overall: 52.2%; HFrEF: 61.1%; HFmrEF: 48.6%; HFpEF: 32.5%). Compared to those on GDMT, patients not receiving quadruple therapy were older (mean age; 59.7 vs 58.1 years), more frequently female (41.3% vs 33.6%), had higher prevalence of comorbidities [HTN (63.5% vs 55.0%), T2DM (58.4% vs 50.3%), CKD (28.4% vs 16.3%)], longer HF duration (3.2 vs 2.8 years), higher LVEF (42.7 % vs 33.6 %), and reduced kidney function (mean eGFR 65.7 vs 72.5 mL/min/1.73m²). Multivariate analysis identified comorbid CKD (odds ratio [OR], 1.9; 95% CI, 1.29–2.78; p=0.0012), increased serum creatinine levels (mg/dL) (OR, 1.5; 95% CI, 1.17–1.96; p=0.0015), and coronary artery disease history (OR, 1.4; 95% CI, 1.07–1.83; p=0.0127) as independently associated with not receiving GDMT.
Conclusion
In this diverse HF cohort from understudied regions, GDMT adoption remains suboptimal across the ejection fraction spectrum in which impaired kidney function appears to be the most significant obstacle. The results underscore the need for tailored strategies to align real-world practice with evidence-based guidelines to improve patient outcomes.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.