Elsevier

JACC: Heart Failure

Volume 11, Issue 5, May 2023, Pages 596-606
JACC: Heart Failure

Clinical Research
Patient Eligibility for Established and Novel Guideline-Directed Medical Therapies After Acute Heart Failure Hospitalization

https://doi.org/10.1016/j.jchf.2022.10.013Get rights and content

Abstract

Background

Acute heart failure (AHF) hospitalization presents an opportunity to optimize pharmacotherapy to improve outcomes.

Objectives

This study’s aim was to define eligibility for initiation of guideline-directed medical therapy and newer heart failure (HF) agents from recent clinical trials in the AHF population.

Methods

The authors analyzed patients with an AHF admission within the CAN-HF (Canadian Heart Failure) registry between January 2017 and April 2020. Heart failure with reduced ejection fraction (HFrEF) was defined as left ventricular ejection fraction (LVEF) ≤40% and heart failure with preserved ejection fraction (HFpEF) as LVEF >40%. Eligibility was assessed according to the major society guidelines or enrollment criteria from recent landmark clinical trials.

Results

A total of 809 patients with documented LVEF were discharged alive from hospital: 455 with HFrEF and 354 with HFpEF; of these patients, 284 had a de novo presentation and 525 had chronic HF. In HFrEF patients, eligibility for therapies was 73.6% for angiotensin receptor–neprilysin inhibitors (ARNIs), 94.9% for beta-blockers, 84.4% for mineralocorticoid receptor antagonists (MRAs), 81.1% for sodium-glucose cotransporter-2 (SGLT2) inhibitors, and 15.6% for ivabradine. Additionally, 25.9% and 30.1% met trial criteria for vericiguat and omecamtiv mecarbil, respectively. Overall, 71.6% of patients with HFrEF (75.5% de novo, 69.5% chronic HF) were eligible for foundational quadruple therapy. In the HFpEF population, 37.6% and 59.9% were eligible for ARNIs and SGLT2 inhibitors based on recent trial criteria, respectively.

Conclusions

The majority of patients admitted with AHF are eligible for foundational quadruple therapy and additional novel medications across a spectrum of HF phenotypes.

Section snippets

Study design and patient population

CAN-HF (Canadian Heart Failure) registry was a retrospective, observational, nonrandomized study of consecutive patients with HF who were inpatient with AHF as primary reason for admission. The design and basic methodology of the CAN-HF registry is reported in a prior publication.19 In brief, patients were enrolled at 7 sites across Quebec, Ontario, Manitoba, and British Columbia between January 2017 and April 2020. There were no exclusion criteria. Chart abstraction of admission and discharge

Baseline characteristics

Across the 7 participating centers, 943 patients were hospitalized with AHF, of whom 869 were discharged alive: 455 with HFrEF and 354 with HFpEF, excluding 60 patients in whom no LVEF data were recorded (Figure 1). Decompensation of chronic HF was more common than de novo presentations, representing 64.2% and 65.8% of admissions with HFrEF and HFpEF, respectively. The median hospital length of stay among all AHF patients was 7 days (IQR: 4-12 days). Patients with HFpEF compared with HFrEF were

Discussion

In this cohort of consecutive HFrEF patients admitted with AHF, 74% to 95% of patients were eligible for 1 of the 4 foundational therapies, and almost three-quarters were eligible for combined quadruple therapy. Furthermore, there is considerable opportunity for adjunct use of novel pharmacotherapies that are less commonly prescribed, such as ivabradine, or not yet approved, such as vericiguat and omecamtiv mecarbil. Similarly, an estimated 3 of 5 patients with HFpEF would be eligible for

Conclusions

Among a large cohort of Canadian patients admitted to the hospital with HF decompensation, a significant proportion are eligible for initiation of disease-modifying pharmacotherapies for treatment of HFrEF and HFpEF. Our hope is that by presenting these data from a contemporary AHF population, we can set a framework for clinicians to consider early and rapid prescription of comprehensive HF therapies. Every attempt should be made to initiate GDMT in all eligible patients before discharge,

Funding Support and Author Disclosures

CAN-HF was funded by Novartis Canada. This study was supported by the Canadian Cardiovascular Institute (CCI-CIC). Dr Hawkins has received speaker and research fees from Novartis; and has received speaker fees from Boehringer Ingelheim. Dr McKelvie has received speaker and research fees from Novartis, Boehringer Ingelheim, AstraZeneca, and Bayer. Dr Joncas has received research grant support or served on advisory boards for and speaking engagements with AstraZeneca, Amgen, Bayer, Boehringer

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