Skip to main content
SpringerLink
Log in

Defining the gap in heart failure treatment in patients with cardiac implantable electronic devices

  • Original Paper
  • Published:
Clinical Research in Cardiology Aims and scope Submit manuscript

Abstract

Background

The use of guideline-directed medical therapy (GDMT) is poorly described in patients with heart failure and reduced ejection fraction (HFrEF) with cardiac resynchronization therapy (CRT) and/or implantable cardioverter defibrillators (ICDs).

Objective

To define the eligibility, uptake, dose, contraindications, and barriers to uptake of contemporary medical therapy in this population.

Methods

Retrospective analysis of consecutive adults with ICD and/or CRT attending two Canadian tertiary centre device clinics between 1 March and 31 May 2021.

Results

From 1005 device clinic consultations, 227 (22.6%) patients with HFrEF and CRT and/or ICD were included. GDMT eligibility was high: beta-blockers (99.6%), mineralocorticoid receptor antagonists (MRA) (89.0%), angiotensin receptor–neprilysin inhibitors (ARNI) (84.6%), and sodium-glucose cotransporter-2 inhibitors (SGLT2I) (87.7%). Contraindications were rare: beta-blockers (0.4%), MRA (11.0%), ARNI (15.4%), and SGLT2I (12.3%). Uptake of GDMT was high for beta-blockers (97.4%) but low for other medications: MRA (63.0%), ARNI (46.7%), SGLT2I (22.9%). Except for SGLT2I (84.6%) and beta-blockers (57.9%), less than one-half of patients were prescribed target-doses of MRA (10.5%), and ARNI (47.7%). Of the visits, GDMT was already optimal in 16%, electrophysiologists acted in 33% (21% prescribed, 7% ordered investigations, 5% referred to heart function services), and in the remaining visits, optimization was either deferred to another cardiologist (20%) or no plan was mentioned (25%), besides other reasons (4%).

Conclusion

Despite broad eligibility for GDMT in patients with HFrEF and ICD/CRT, significant gaps in prescription and titration exist. Our results highlight the need to embed quality assurance initiatives in cardiac device clinics to improve HFrEF care.

Graphical abstract

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig.1
Fig.2
Fig.3
Fig.4
Fig.5

Similar content being viewed by others

Abbreviations

ACEI:

Angiotensin-converting enzyme inhibitor

ARB:

Angiotensin receptor blocker

ARNI:

Angiotensin receptor–neprilysin inhibitor

CRT:

Cardiac resynchronization therapy

GDMT:

Guideline directed medical therapy

HF:

Heart failure

HFrEF:

Heart failure with reduced ejection fraction

ICD:

Implantable cardioverter defibrillator

LVEF:

Left ventricular ejection fraction

MRA:

Mineralocorticoid receptor antagonist

SGLT2I:

Sodium-glucose cotransporter-2 inhibitors

References

  1. Hauptman PJ, Swindle JP, Masoudi FA, Burroughs TE (2010) Underutilization of beta-blockers in patients undergoing implantable cardioverter-defibrillator and cardiac resynchronization procedures. Circ Cardiovasc Qual Outcomes 3(2):204–211. https://doi.org/10.1161/CIRCOUTCOMES.109.880450

    Article  Google Scholar 

  2. Roth GA, Poole JE, Zaha R, Zhou W, Skinner J, Morden NE (2016) Use of guideline-directed medications for heart failure before cardioverter-defibrillator implantation. J Am Coll Cardiol 67(9):1062–1069. https://doi.org/10.1016/j.jacc.2015.12.046

    Article  Google Scholar 

  3. Witt CT, Kronborg MB, Nohr EA, Mortensen PT, Gerdes C, Nielsen JC (2015) Optimization of heart failure medication after cardiac resynchronization therapy and the impact on long-term survival. Eur Heart J Cardiovasc Pharmacother 1(3):182–188. https://doi.org/10.1093/ehjcvp/pvv016

    Article  CAS  Google Scholar 

  4. Martens P, Verbrugge FH, Nijst P, Bertrand PB, Dupont M, Tang WH et al (2017) Feasibility and association of neurohumoral blocker up-titration after cardiac resynchronization therapy. J Card Fail 23(8):597–605. https://doi.org/10.1016/j.cardfail.2017.03.001

    Article  CAS  Google Scholar 

  5. Martens P, Dupont M, Mullens W (2020) Reduced occurrence of appropriate therapy for ventricular arrhythmias after beta-blocker uptitration following implant of a primary prevention CRT-defibrillator. Acta Cardiol 75(1):49–53. https://doi.org/10.1080/00015385.2018.1547469

    Article  Google Scholar 

  6. Salimian S, Deyell MW, Andrade JG, Chakrabarti S, Bennett MT, Krahn AD et al (2021) Heart failure treatment in patients with cardiac implantable electronic devices: opportunity for improvement. Heart Rhythm O2. 2(6):698–709

    Article  Google Scholar 

  7. Jorsal A, Pryds K, McMurray JJV, Wiggers H, Sommer A, Nielsen JC et al (2020) Optimizing heart failure treatment following cardiac resynchronization therapy. Clin Res Cardiol 109(5):638–645. https://doi.org/10.1007/s00392-019-01553-4

    Article  CAS  Google Scholar 

  8. McDonald M, Virani S, Chan M, Ducharme A, Ezekowitz JA, Giannetti N et al (2021) CCS/CHFS heart failure guidelines update: defining a new pharmacologic standard of care for heart failure with reduced ejection fraction. Can J Cardiol 37(4):531–546. https://doi.org/10.1016/j.cjca.2021.01.017

    Article  Google Scholar 

  9. Maddox TM, Januzzi JL Jr, Allen LA, Breathett K, Butler J, Davis LL et al (2021) 2021 Update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction: a report of the American college of cardiology solution set oversight committee. J Am Coll Cardiol 77(6):772–810. https://doi.org/10.1016/j.jacc.2020.11.022

    Article  Google Scholar 

  10. Parikh KS, Lippmann SJ, Greiner M, Heidenreich PA, Yancy CW, Fonarow GC et al (2017) Scope of sacubitril/valsartan eligibility after heart failure hospitalization: findings from the GWTG-HF Registry (Get With The Guidelines-Heart Failure). Circulation 135(21):2077–2080

    Article  Google Scholar 

  11. Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH et al (2008) Influence of beta-blocker continuation or withdrawal on outcomes in patients hospitalized with heart failure: findings from the OPTIMIZE-HF program. J Am Coll Cardiol 52(3):190–199

    Article  CAS  Google Scholar 

  12. Vaduganathan M, Greene SJ, Zhang S, Grau-Sepulveda M, DeVore AD, Butler J et al (2021) Applicability of US food and drug administration labeling for dapagliflozin to patients with heart failure with reduced ejection fraction in us clinical practice: The Get With the Guidelines-Heart Failure (GWTG-HF) Registry. JAMA cardiol 6(3):267–275

    Article  Google Scholar 

  13. Greene SJ, Butler J, Albert NM, DeVore AD, Sharma PP, Duffy CI et al (2018) Medical therapy for heart failure with reduced ejection fraction: the CHAMP-HF registry. J Am Coll Cardiol 72(4):351–366

    Article  Google Scholar 

  14. DeVore AD, Hill CL, Thomas L, Sharma PP, Albert NM, Butler J et al (2018) Patient, provider, and practice characteristics associated with sacubitril/valsartan use in the United States. Circ Heart Fail 11(9):e005400. https://doi.org/10.1161/CIRCHEARTFAILURE.118.005400

    Article  Google Scholar 

  15. Heywood JT, Fonarow GC, Yancy CW, Albert NM, Curtis AB, Gheorghiade M et al (2010) Comparison of medical therapy dosing in outpatients cared for in cardiology practices with heart failure and reduced ejection fraction with and without device therapy: report from IMPROVE HF. Circ Heart Fail 3(5):596–605. https://doi.org/10.1161/CIRCHEARTFAILURE.109.912683

    Article  Google Scholar 

  16. Mullens W, Auricchio A, Martens P, Witte K, Cowie MR, Delgado V et al (2020) Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care: a joint position statement from the Heart Failure Association (HFA), European Heart Rhythm Association (EHRA), and European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology. Eur J of Heart Fail 22(12):2349–2369

    Article  Google Scholar 

  17. D’Onofrio A, Palmisano P, Rapacciuolo A, Ammendola E, Calo L, Ruocco A et al (2017) Effectiveness of a management program for outpatient clinic or remote titration of beta-blockers in CRT patients: The RESTORE study. Int J Cardiol 236:290–295. https://doi.org/10.1016/j.ijcard.2017.02.015

    Article  Google Scholar 

  18. Bristow M, Saxon L, Boehmer J, Krueger S, Kass D, De MT et al (2004) Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 350(21):2140–2150

    Article  CAS  Google Scholar 

  19. Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L et al (2005) The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 352(15):1539–1549

    Article  CAS  Google Scholar 

  20. Savarese G, Carrero JJ, Pitt B, Anker SD, Rosano GM, Dahlström U et al (2018) Factors associated with underuse of mineralocorticoid receptor antagonists in heart failure with reduced ejection fraction: an analysis of 11 215 patients from the Swedish Heart Failure Registry. Eur J Heart Fail 20(9):1326–1334

    Article  CAS  Google Scholar 

  21. Aranda JM Jr, Woo GW, Conti JB, Schofield RS, Conti CR, Hill JA (2005) Use of cardiac resynchronization therapy to optimize beta-blocker therapy in patients with heart failure and prolonged QRS duration. Am J Cardiol 95(7):889–891. https://doi.org/10.1016/j.amjcard.2004.12.023

    Article  CAS  Google Scholar 

  22. Adlbrecht C, Hulsmann M, Gwechenberger M, Strunk G, Khazen C, Wiesbauer F et al (2009) Outcome after device implantation in chronic heart failure is dependent on concomitant medical treatment. Eur J Clin Invest 39(12):1073–1081. https://doi.org/10.1111/j.1365-2362.2009.02217.x

    Article  Google Scholar 

  23. Schmidt S, Hurlimann D, Starck CT, Hindricks G, Luscher TF, Ruschitzka F et al (2014) Treatment with higher dosages of heart failure medication is associated with improved outcome following cardiac resynchronization therapy. Eur Heart J 35(16):1051–1060. https://doi.org/10.1093/eurheartj/eht514

    Article  CAS  Google Scholar 

  24. Mantziari L, Guha K, Khalique Z, McDonagh T, Sharma R (2012) Relation of dosing of the renin-angiotensin system inhibitors after cardiac resynchronization therapy to long-term prognosis. Am J Cardiol 109(11):1619–1625. https://doi.org/10.1016/j.amjcard.2012.01.387

    Article  CAS  Google Scholar 

  25. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M et al (2021) 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 42(36):3599–3726

    Article  CAS  Google Scholar 

  26. Greene SJ, Khan MS (2021) Quadruple medical therapy for heart failure: medications working together to provide the best care. J Am Coll Cardiol 77(11):1408–1411

    Article  Google Scholar 

  27. Bhatt AS, Vaduganathan M, Claggett BL, Liu J, Packer M, Desai AS et al (2021) Effect of sacubitril/valsartan vs. enalapril on changes in heart failure therapies over time: the PARADIGM-HF trial. Eur J Heart Fail 23(9):1518–1524

    Article  CAS  Google Scholar 

  28. Ferreira JP, Zannad F, Pocock SJ, Anker SD, Butler J, Filippatos G et al (2021) Interplay of mineralocorticoid receptor antagonists and empagliflozin in heart failure: EMPEROR-Reduced. J Am Coll Cardiol 77(11):1397–1407

    Article  CAS  Google Scholar 

  29. Serenelli M, Jackson A, Dewan P, Jhund PS, Petrie MC, Rossignol P et al (2020) Mineralocorticoid receptor antagonists, blood pressure, and outcomes in heart failure with reduced ejection fraction. Heart Fail 8(3):188–198

    Google Scholar 

  30. Serenelli M, Böhm M, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA et al (2020) Effect of dapagliflozin according to baseline systolic blood pressure in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF). Eur Heart J 41(36):3402–3418

    Article  CAS  Google Scholar 

  31. Boehmer JP, Hariharan R, Devecchi FG, Smith AL, Molon G, Capucci A et al (2017) A multisensor algorithm predicts heart failure events in patients with implanted devices: results from the MultiSENSE study. JACC Heart Failure 5(3):216–225. https://doi.org/10.1016/j.jchf.2016.12.011

    Article  Google Scholar 

  32. Wever-Pinzon O, Drakos SG, Fang JC (2015) Team-based care for advanced heart failure. Heart Fail Clin 11(3):467–477

    Article  Google Scholar 

  33. Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM (1995) A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 333(18):1190–1195

    Article  CAS  Google Scholar 

  34. Zaman S, Zaman SS, Scholtes T, Shun-Shin MJ, Plymen CM, Francis DP et al (2017) The mortality risk of deferring optimal medical therapy in heart failure: a systematic comparison against norms for surgical consent and patient information leaflets. Eur J Heart Fail 19(11):1401–1409. https://doi.org/10.1002/ejhf.838

    Article  Google Scholar 

  35. Jarjour M, Henri C, de Denus S, Fortier A, Bouabdallaoui N, Nigam A et al (2020) Care gaps in adherence to heart failure guidelines: clinical inertia or physiological limitations? JACC Heart Failure 8(9):725–738. https://doi.org/10.1016/j.jchf.2020.04.019

    Article  Google Scholar 

Download references

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, Canada

    Samaneh Salimian, Nima Moghaddam, Marc W. Deyell, Sean A. Virani, Matthew T. Bennett, Andrew D. Krahn, Jason G. Andrade & Nathaniel M. Hawkins

  2. St. Paul’s Hospital, University of British Columbia, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada

    Nathaniel M. Hawkins

Authors
  1. Samaneh Salimian
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nima Moghaddam
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marc W. Deyell
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sean A. Virani
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Matthew T. Bennett
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Andrew D. Krahn
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jason G. Andrade
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Nathaniel M. Hawkins
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nathaniel M. Hawkins.

Ethics declarations

Conflict of interest

Financial interests: JA received grants and personal fees from Medtronic, Bayer, BMS-Pfizer, Servier; grants from Baylis; personal fees from Biosense-Webster. SS received salary support for quality improvement from Novartis, MD received grants and personal fees from Biosense Webster, personal fees from Medtronic, Bayer, BMS-Pfizer and Abbott, and NH received speakers’ fees from Novartis.

Ethical approval

After discussion with the Research Ethics Board the study was exempted from further review since quality improvement activities are exempt under article 2.5 of TCPS2, the overarching ethical framework for research involving human participants in Canada.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 145 kb)

Supplementary file2 (PDF 117 kb)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Salimian, S., Moghaddam, N., Deyell, M.W. et al. Defining the gap in heart failure treatment in patients with cardiac implantable electronic devices. Clin Res Cardiol 112, 158–166 (2023). https://doi.org/10.1007/s00392-022-02123-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00392-022-02123-x

Keywords

Search

Navigation