Guideline-Directed Medical Therapy Improves Outcomes in HFrEF

Early initiation of guideline-directed medical therapy in patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF) demonstrates a more notable improvement of left ventricular ejection fraction, brain natriuretic peptide (BNP), and heart failure-related hospital readmission, according to research results presented at the Heart Failure Society of American 2024 Annual Meeting.¹

Guideline-directed medical therapy improved numerous outcomes in heart failure with reduced ejection fraction (HFrEF) | Image credit: stock.adobe.com

Although evidence from randomized clinical trials of guideline-directed medical therapy in HFrEF is strong, indicating that utilization improves mortality and outcomes—including reduced heart failure-related hospitalization—the use of guideline-directed medical therapy continues to be suboptimal. Efforts, including guidelines and quality improvement initiatives, have been implemented to mitigate these gaps, but “results remain unsatisfactory,” per researchers. Anticipated long-term benefits of quadruple therapy with a beta-blocker, angiotensin receptor neprilysin inhibitor (ARNi), sodium-glucose cotransporter 2 inhibitor (SGLT2i), and mineralocorticoid receptor antagonist (MRA) reduce cardiovascular death and increase overall survival compared with conventional therapy (a combination angiotensin converting enzyme inhibitors or angiotensin receptor blockers and beta blockers), making “aggressive initiation of [guideline-directed medical therapy] …a high priority.”

In order to evaluate the impact of early guideline-directed medical therapy initiation, investigators analyzed intensified use of ARNis and SGLT2is in patients with new-onset or chronic HFrEF with ischemic and nonischemic cardiomyopathy.

Between 2020 and 2023, a total of 284 patients at a clinic were enrolled in a guideline-directed medical therapy optimization program led by nurse practitioners and pharmacists. patients were followed until achieving either the target or maximum tolerated dose of either triple or quadruple therapy. Data included echocardiography results, lab values, New York Heart Association class, and heart failure-related hospital readmissions.

READ MORE: Outcomes in Transthyretin Amyloid Cardiomyopathy Examined

Within the study cohort (mean age, 64 years; 70% men), 94.9% were enrolled within 3 months of evaluation in the heart failure clinic. More patients had new onset heart failure—55%—and the majority of cases were nonischemic (62.3%).

At program completion, investigators saw a similar increase in both groups of patients who were on triple and quadruple therapy. The use of both ARNis and SGLT2is were higher in both groups at the end of evaluation (79.2% s 84.9% and 64.8% vs 65.6%). A higher percentage of patients in the new onset group experienced improvement in left ventricular ejection fraction, with a greater absolute degree of improvement. NYHA class also improved in both groups throughout the intervention; a reduction in BNP was noted, and heart failure-related hospital readmissions were “significantly lower in the new-onset vs the chronic group) 7.5% vs 19.2%).

“The outcome of intensified use of ARNi and SGLT2i underscores the urgency of initiating treatment immediately after diagnosis of HFrEF,” the researchers concluded. “Despite etiology, early initiation of [guideline-directed medical therapy] in newly diagnosed HFrEF demonstrates a greater improvement of [left ventricular ejection fraction], reduction in BNP, and [heart failure]-related readmission compared to chronic HFrEF.”

Click here for more coverage of the Heart Failure Society of America 2024 Annual Meeting.

Reference

1. Baksh G, Haydo M, Reesor H, Zhu J, Popjes E. The impact of increased early utilization of angiotensin receptor neprilysin inhibitor (ARNi) And sodium glucose cotransporter 2 inhibitors (SGLT2i) in new onset and chronic hfref. Presented at: Heart Failure Society of America 2024 Annual Meeting; September 27-30, 2024; Atlanta, GA. Poster 407.