Suboptimal use of evidence-based medical therapies in patients with HFrEF and CKD

This study showed that prescription rates of evidence-based medical therapies are suboptimal in patients with comorbid HFrEF and CKD, even at eGFR levels where therapies are not contraindicated by kidney dysfunction.

Kidney Function and Outcomes in Patients Hospitalized with Heart Failure
Literature - Patel RB, Fonarow GC, Greene SJ et al. - J Am Coll Cardiol. 2021 May 4;S0735-1097(21)04968-8. doi: 10.1016/j.jacc.2021.05.002.

Introduction and methods

Not much is known about how frequently evidence-based medical therapies are prescribed for patients with HFrEF and CKD. This study evaluated care patterns and outcomes in adult patients hospitalized for HF across the spectrum of kidney function in the Get With The Guidelines-Heart Failure (GWTG-HF) registry.

The GWTG-HF program prospectively collects information about patients with a primary discharge diagnosis of HF from participating centers in the US [1]. The primary analytic cohort included 365 494 adult patients (mean age 72±15 years), hospitalized for HF between January 1, 2014 and September 30, 2019 across 418 GWTG-HF sites. Patients were categorized based on EF criteria (HFrEF: EF ≤40%, HFmrEF: EF 41-49%, and HFpEF: EF ≥50%) and based on eGFR at discharge (>90, 60 to<90, 45 to <60, 30 to <45, <30 mL/min/1.73m², and dialysis).

In-hospital mortality was assessed in the primary analytic cohort according to admission eGFR. Achievement of quality measures among HFrEF patients was assessed in a secondary analytic cohort that excluded patients with EF >40% and patients with missing EF data, leaving 157,439 participants from 407 sites. The primary metrics of interest for patients with HFrEF were: use of ACEi, ARB or ARNI, β-blocker, and/or MRA at discharge, or prescription of triple therapy (ACEi/ARB/ARNI + β-blocker + MRA).

Main results

• Lower admission eGFR was significantly associated with higher in-hospital mortality in a graded fashion, with in-house mortality rates of 1.1%, 1.5%, 2.0%, 3.0%, 5.0%, and 4.2% for admission eGFR of ≥90, 60-89, 45-59, 30-44, <30 mL/min/1.73m² and dialysis respectively, P<0.001. Lower admission eGFR categories were independently associated with in-hospital mortality across the three EF groups after adjustment for multivariable covariates. Interaction analysis showed that the association between admission eGFR and in-hospital mortality was stronger in HFrEF compared to HFmrEF and HFpEF (P for interaction= 0.045).
• Prescription of β-blockers was significantly lower in a graded fashion at lower discharge eGFR (90%, 89%, 88%, 86%, 80%, and 79% for discharge eGFR of ≥90, 60-89, 45-59, 30-44, <30 mL/min/1.73m² and dialysis respectively, P<0.001).
• Similar patterns were seen for prescription of MRA (45%, 40%, 35%, 26%, 14%, and 5% for discharge eGFR groups of ≥90, 60-89, 45-59, 30-44, <30 mL/min/1.73m² and dialysis respectively, P<0.001) and for the prescription of ARNI (7%, 7%, 6%, 5%, 3%, and 2% for discharge eGFR of ≥90, 60-89, 45-59, 30-44, <30 mL/min/1.73m² and dialysis respectively, P<0.001).
• A similar pattern was also seen for prescription rates of ACEi/ARB, however the lowest prescription rates were seen in patients with eGFR<30 mL/min/1.73m² (78%, 73%, 63%, 45%, 24%, and 38% for discharge eGFR groups of ≥90, 60-89, 45-59, 30-44, <30 mL/min/1.73m² and dialysis respectively, P<0.001).
• Prescription rates of triple therapy (ACEi/ARB/ARNI + β-blocker + MRA) also decreased with lower eGFR categories: 38%, 33%, 25%, 15%, 5%, and 3% for discharge eGFR of ≥90, 60-89, 45-59, 30-44, <30 mL/min/1.73m² and dialysis respectively, P<0.001.
• Lower discharge eGFR was associated with a lower likelihood of having a post-discharge appointment made (70%, 67%, 65%, 60%, 54%, and 51% for eGFR ≥90, 60-89, 45-59, 30-44, <30 mL/min/1.73m² and dialysis, respectively; P<0.001) and having and follow up visit made within 7 days of discharge (62%, 60%, 59%, 56%, 50%, and 52% for eGFR ≥90, 60-89, 45-59, 30-44, <30 mL/min/1.73m² and dialysis, respectively; P<0.001).

Conclusion

References

Find this article online at J Am Coll Cardiol.