Starting HF Meds In-Hospital: Progress, Opportunities


Most patients aren’t receiving all the meds they should based on guidelines, nor are they getting them at the most effective time in their disease course, suggests a registry study of patients in the United States hospitalized with heart failure with reduced ejection fraction (HFrEF).

Only a sixth were on all guideline-directed medical therapies (GDMTs) at admission, but that improved to one third by discharge. On average, one such medication was initiated per patient for every 6 days in the hospital.

Shortfalls in predischarge GDMT initiation disproportionately landed on women, patients at rural centers, and those with renal failure or other comorbidities. But they didn’t seem related to patient race or ethnicity in the study reported June 14 in JACC: Heart Failure.

The analysis covers the 3 years preceding the May 2020 first-time approval of a sodium-glucose cotransporter 2 (SGLT2) inhibitor for nondiabetic patients with HFrEF, and therefore doesn’t cover such drugs for that indication. The SGLT2 inhibitors would later join beta-blockers, renin-angiotensin system (RAS) inhibitors, and mineralocorticoid receptor antagonists (MRAs) in the quartet of core GDMT medications broadly indicated for HFrEF.

In-hospital initiation of GDMT for HFrEF is considered a predictor of being on those meds after discharge and is itself guideline-recommended. There’s clear evidence that treatment with the four core medications boosts survival and cuts rehospitalization risk, and that “getting those onboard as soon as possible will eventually benefit many patients,” Paul L. Hess, MD, MHS, told | Medscape Cardiology.

Hess, University of Colorado Anschutz Medical Campus, Aurora, is senior author on the report from the Get With The Guidelines-Heart Failure (GWTG-HF) quality improvement program of the American Heart Association. Lead author is Stanley A. Swat, MD, MSCS, from the same institution.

Broad uptake of new medical therapies into practice may sometimes take 15 or more years from first publication, Hess said, so, “I find it encouraging in the study that over a shorter time period, 2017 to 2020, there was improvement.”

Indeed, the odds of in-hospital initiation of an indicated med during that period on average climbed a significant 8% every 3 months, the report states.

The finding suggests that “heart failure hospitalization is, in and of itself, an important intervention for getting folks on the appropriate medications,” Hess said. It also means “we’re getting better at it,” at least at the study’s 160 GWTG-HF participating hospitals nationwide.

Those centers, the report acknowledges, varied in size, geography, and teaching status but were not necessarily representative of all US hospitals. In another potential limitation, the study couldn’t account for patients who weren’t prescribed all indicated meds for clinically valid reasons. It excluded patients with “clear contraindications,” Hess said. But there could have been “legitimate reasons” some indicated medications weren’t always prescribed, including patient frailty, hemodynamic intolerance, renal dysfunction, or polypharmacy concerns.

“Positive takeaways” from the analysis, notes an accompanying editorial, include improved prescription rates for key GDMT categories across more than 3 years of data, and evidence that in-hospital initiation “was feasible and, at least for some medications, reliably undertaken.”

Of note, new GDMT prescriptions from admission to discharge went from 70% to almost 98% for beta-blockers, 59% to about 91% for RAS inhibitors, about 26% to 56% for MRAs, and 15.5% to 27.4% for hydralazine/nitrates, observe the editorialists, Karen E. Joynt Maddox, MD, MPH, and Daniel K. Fox, MD, PhD, Washington University, St Louis, Missouri.

“Key areas for improvement,” they note, include prescriptions for women, who were 12% less likely than men to have appropriate GDMT initiated during hospitalization (P < .001); and practice at rural hospitals, which were 40% less likely than urban centers to have patients on full GDMT by discharge (P = .017).

Although only 2.6% of the GWTG-HF centers were in rural locations, “rural hospitals make up approximately one-third of general acute-care hospitals in this country,” the editorial states. They therefore “represent a key source of health disparity” in the United States in need of further study.

The analysis of 50,170 patients hospitalized with HFrEF compared the number of GDMT meds for which they were eligible, on at-hospital admission, and by discharge.

The drug categories included “evidence based beta blockers,” that is, bisoprolol, carvedilol, or sustained-release metoprolol; RAS inhibitors, specifically angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or sacubitril/valsartan (Entresto); MRAs; SGLT2 inhibitors in patients with diabetes; diuretics for congestion; oral anticoagulants for atrial fibrillation; and hydralazine/nitrates in African Americans.

About 15% of the patients at hospital admission were on all indicated HFrEF meds for which they were eligible. The proportion more than doubled to 32.8% by discharge.

Factors significantly associated with reduced odds for in-hospital GDMT initiation include older age (odds ratio [OR}, 0.94 per 5-year increment), being female vs male (OR, 0.88), rural location (OR, 0.60), Medicaid vs Medicare or private insurance (OR, 0.93), stroke history (OR, 0.91), peripheral artery disease (OR, 0.93), chronic obstructive pulmonary disease or asthma (OR, 0.86), and renal insufficiency (OR, 0.77).

The findings suggest that there has been at least some progress in getting hospitalized patients “on the right meds” by discharge, Hess observed. To help address shortfalls in some patient groups, “there is interest in engaging pharmacists in helping us encourage providers on the frontlines to initiate and titrate medications.”

J Am Coll Cardiol HF. Published online June 13, 2023. Full Text, Editorial

The GWTG-HF program “is sponsored, in part, by Novartis, Boehringer Ingelheim, Novo Nordisk, AstraZeneca, Bayer, Tylenol, and Alnylam Pharmaceuticals.” Hess and Swat disclosed no relevant financial relationships; potential conflicts for the other authors are in the report. Maddox discloses serving on the Health Policy Advisory Council for the Centene Corporation. Fox reports no relevant financial relationships.

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