Physicians' Academy for Cardiovascular Education

Patients with obesity more often receive optimal GDMT in HFrEF

Use of and association between heart failure pharmacological treatments and outcomes in obese versus non-obese patients with heart failure with reduced ejection fraction: data from the Swedish Heart Failure Registry

Literature - Cappelletto C, Stolfo D, Orsini N, et al. - Eur J Heart Fail. 2023 Feb 13. doi: 10.1002/ejhf.2795.

Introduction and methods


Approximately 40% of patients with HFrEF is obese (BMI ≥ 30 kg/m²) [1]. Nevertheless, this patient population is underrepresented in RCTs in HFrEF. Registry-based studies on large HF cohorts may provide insight how guideline-directed medical therapies (GDMT) affect patients with HF with and without obesity.

Aim of the study

This study investigated the use and dosing of GDMT and associated outcomes in patients with HFrEF with and without obesity.



Patients from the Swedish HF Registry (SwedeHF) with HFrEF, <6 months after HF diagnosis, and with available BMI data were included in this study. 16,116 patients (73% male) with registrations from 10 May 2000 and 31 December 2019 were included. 12,171 patients (76%) did not have obesity and 3,945 patients (24%) had obesity. Patients with obesity were younger compared to patients without obesity (mean 71 vs 77 years old). GDMT for HFrEF included, at the time, RASi/ARNI, beta-blockers, MRAs and a combination of RASi/ARNI, beta-blockers and MRAs (referred to as triple therapy). SGLT2i were not considered as they were introduced as GDMT for HFrEF after data collection. The median follow-up period was 2.21 years (IQR 0-17).


The primary outcome was 5-year all-cause mortality. Secondary outcomes were 5-year CV-mortality, and 5-year first HF hospitalization.

Main results

Use of GDMT



Patients with HFrEF and with obesity more often received GDMT and with higher dosages, even after adjusting for factors related to tolerance. This suggests that perceived tolerance issues, but not necessary the actual tolerance issue, limits GDMT in a portion of patients with HFrEF.

RASi/ARNI and beta blockers were associated with lower mortality regardless of obesity. Competing risk analysis showed that this association of RASi/ARNI with lower risk of CV mortality was greater in patients with obesity. In addition, RASi/ARNI was associated with lower risk of HF hospitalization in patients with obesity compared to patients without obesity.

The authors highlight that “our results do not completely exclude a different effectiveness of HF treatments in obese versus non-obese patients, but represent a call for further and more focused research adopting e.g., more precise parameters to assess obesity (measurements of adipose tissue distribution, waist-to-hip ratio, etc.) and more adequate study design, e.g., stratified randomization according to obesity in RCTs.”.


Show references

Find this article online at Eur J Heart Fail.

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