Treatment Differences in Medical Therapy for Heart Failure With Reduced Ejection Fraction Between Sociodemographic Groups

Determinants of Guideline-Directed Medical Therapy Implementation During Heart Failure Hospitalization

Background

Despite evidence that guideline-directed medical therapies (GDMTs) improve outcomes in patients with heart failure (HF) with reduced ejection fraction (HFrEF), implementation remains suboptimal.

Objectives

The purpose of this study was to measure GDMT implementation during acute HFrEF hospitalization, evaluate the association between socioeconomic factors and GDMT implementation, and assess the association of GDMT utilization with subsequent clinical events.

Methods

Retrospective determination of GDMT utilization using a modified optimal medical therapy (mOMT) score (which accounts for specific contraindications to drugs) during unplanned HF hospitalization of consecutive adult patients with new-onset or previously diagnosed HFrEF from 2017 to 2018. Outcomes included discharge mOMT score, association between socioeconomic factors and GDMT implementation (assessed using both the Mann-Whitney U test for binary variables and the Kruskall-Wallace for nonbinary variables), composite outcome 1-year all-cause mortality and 1-year HF readmission, and each component as a function of discharge mOMT score (assessed using univariate and multivariable Cox proportional hazards regression models).

Results

Of 391 patients fulfilling entry criteria (of which 152 [38.9%] had new-onset HFrEF), only 49 (12.5%) had a perfect or near-perfect discharge mOMT score. Black patients and those experiencing homelessness had significantly lower discharge mOMT scores. Higher discharge mOMT score is associated with a lower rate of composite endpoint events, particularly in patients with new-onset HFrEF. Overall, a 0.1-increase in the mOMT score resulted in a 9.2% reduction in the composite endpoint.

Conclusions

Suboptimal implementation of GDMT during HF hospitalization is widespread and is associated with a worse outcome. Black patients and patients experiencing homelessness were less likely to have GDMT optimized.

Sex Differences in Cardiac and Clinical Phenotypes and Their Relation to Outcomes in Patients with Heart Failure

Biological sex is one of the major factors characterizing the heart failure (HF) patient phenotype. Understanding sex-related differences in HF is crucial to implement personalized care for HF patients with various phenotypes. There are sex differences in left ventricular (LV) remodeling patterns in the HF setting, namely, more likely concentric remodeling and diastolic dysfunction in women and eccentric remodeling and systolic dysfunction in men. Recently supra-normal EF (snLVEF) has been recognized as a risk of worse outcome. This pathology might be more relevant in female patients. The possible mechanism may be through coronary microvascular dysfunction and sympathetic nerve overactivation from the findings of previous studies. Further, estrogen deficit might play a significant role in this pathophysiology. The sex difference in body composition may also be related to the difference in LV remodeling and outcome. Lower implementation in guideline-directed medical therapy (GDMT) in female HFrEF patients might also be one of the factors related to sex differences in relation to outcomes. In this review, we will discuss the sex differences in cardiac and clinical phenotypes and their relation to outcomes in HF patients and further discuss how to provide appropriate treatment strategies for female patients.

Trends and site-level variation of novel cardiovascular medication utilization among patients admitted for heart failure or coronary artery disease in the US Veterans Affairs System: 2017-2021

BACKGROUND

We assessed trends in novel cardiovascular medication utilization in US Veterans Affairs (VA) for angiotensin receptor-neprilysin inhibitors (ARNI), sodium-glucose cotransporter-2 Inhibitors (SGLT2i), and glucagon-like peptide-1 receptor agonists (GLP-1 RA).

METHODS

We retrospectively identified cohorts from 114 VA hospitals with admission for prevalent 1) systolic heart failure (HF, N = 82,375) or 2) coronary artery disease and diabetes (CAD+T2D, N = 74,209). Site-level data for prevalent filled prescriptions were assessed at hospital admission, discharge, or within 6 months of discharge. Variability among sites was estimated with median odds ratios (mOR), and within-site Pearson correlations of utilization of each medication class were calculated. Site- and patient-level characteristics were compared by high-, mixed-, and low-utilizing sites.

RESULTS

ARNI and SGTL2i use for HF increased from <5% to 20% and 21%, respectively, while SGTL2i or GLP-1 RA use for CAD+T2D increased from <5% to 30% from 2017 to 2021. Adjusted mOR and 95% confidence intervals for ARNI, SGTL2i for HF, and SGTL2i or GLP-1 RA for CAD+T2D were 1.73 (1.64-1.91), 1.72 (1.59-1.81), and 1.53 (1.45-1.62), respectively. Utilization of each medication class correlated poorly with use of other novel classes (Pearson <0.38 for all). Higher patient volume, number of beds, and hospital complexity correlated with high-utilizing sites.

CONCLUSIONS

Utilization of novel medications has increased over time but remains suboptimal for US Veterans with HF and CAD+T2D, with substantial site-level heterogeneity despite a universal medication formulary and low out-of-pocket costs for patients. Future work should include further characterization of hospital- and clinician-level practice patterns to serve as targets to increase implementation.

Eliminating Health Disparities in Atrial Fibrillation, Heart Failure, and Dyslipidemia: A Path Toward Achieving Pharmacoequity

PURPOSE OF REVIEW

Pharmacoequity refers to the goal of ensuring that all patients have access to high-quality medications, regardless of their race, ethnicity, gender, or other characteristics. The goal of this article is to review current evidence on disparities in access to cardiovascular drug therapies across sociodemographic subgroups, with a focus on heart failure, atrial fibrillation, and dyslipidemia.

RECENT FINDINGS

Considerable and consistent disparities to life-prolonging heart failure, atrial fibrillation, and dyslipidemia medications exist in clinical trial representation, access to specialist care, prescription of guideline-based therapy, drug affordability, and pharmacy accessibility across racial, ethnic, gender, and other sociodemographic subgroups. Researchers, health systems, and policy makers can take steps to improve pharmacoequity by diversifying clinical trial enrollment, increasing access to inpatient and outpatient cardiology care, nudging clinicians to increase prescription of guideline-directed medical therapy, and pursuing system-level reforms to improve drug access and affordability.