Renal function and therapeutic inertia: a gap between eligibility and prescription of guideline-directed medical therapy in hospitalized reduced and mildly reduced ejection fraction patients
M Silva, R Brandao, A Tomas, L Marques, R Vilar, A Curto, I Alexandre, F Henriques, J Oliveira, A NepomucenoAbstract
Background
Current guidelines emphasize the early initiation of the four foundational pillars of therapy for heart failure with reduced (HFrEF) and mildly reduced ejection fraction (HFmrEF). However, renal dysfunction is often cited as a clinical barrier to treatment optimization.
Purpose
To evaluate the impact of renal function on the prescription of guideline-directed medical therapy (GDMT) and to identify patterns of therapeutic inertia in patients hospitalized for acute decompensated heart failure (ADHF).
Methods
We retrospectively analyzed HFrEF and HFmrEF patients admitted to a district hospital from September 2021 to 2023. We considered eligible for mineralocorticoid receptor antagonists (MRA), angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARBs) and angiotensin receptor/neprilysin inhibitor (ARNI), patients with estimated glomerular filtration rate (eGFR) >30mL/min/1.73m² and serum potassium <5.0mmol/L and for SGLT2 inhibitors (SGLT2i), patients with eGFR >25mL/min/1.73m². We did not consider any restriction related to renal function for beta-blocker prescription. Therapeutic inertia was defined as the failure to initiate GDMT in eligible patients.
Results
Among the 150 patients included, 56% were male, with a mean age of 77 ± 20 years. The mean LVEF was 35 ± 19%, and the median eGFR was 56.1 mL/min/1.73 m². Of those eligible, 73.4% were not prescribed MRA, 71.9% were not receiving ACEi, ARBs, or ARNIs, and 77.6% were not treated with SGLT2i. Even with preserved renal function (eGFR >60mL/min/1.73m²), only 44.4% received ≥ 3 pillars. In multivariable logistic regression, neither age (OR 0.980; p=0.272) nor eGFR (OR 0.985; p=0.565) were independent predictors for GDMT optimization. Notably, even in patients with optimal renal function (eGFR >90mL/min/1.73m²), the trend toward higher prescription rates (OR 6.278) failed to reach statistical significance (p=0.402), suggesting the pervasiveness of therapeutic inertia regardless of clinical eligibility.
Conclusions
Our findings indicate a lower use of guideline-directed medical therapy in HFrEF and HFmrEF that does not appear to be explained by objective renal contraindications, as eGFR was not independently associated with prescribing patterns. These results suggest that concerns related to renal function may influence clinical decision-making; however, other clinical, contextual, and patient-specific factors not captured in this study are also likely to contribute. A better understanding of these determinants will be important to further align clinical practice with evidence-based recommendations.