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Greene SJ, Ayodele I, Pierce JB, Khan MS, Lewsey SC, Yancy CW, Alhanti B, Van Spall HGC, Allen LA, Fonarow GC. Eligibility and Projected Benefits of Rapid Initiation of Quadruple Therapy for Newly Diagnosed Heart Failure. JACC. HEART FAILURE 2024; 12:1365-1377. [PMID: 38597866 DOI: 10.1016/j.jchf.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND U.S. nationwide estimates of the proportion of patients newly diagnosed with heart failure with reduced ejection fraction (HFrEF) eligible for quadruple medical therapy, and the associated benefits of rapid implementation, are not well characterized. OBJECTIVES This study sought to characterize the degree to which patients newly diagnosed with HFrEF are eligible for quadruple medical therapy, and the projected benefits of in-hospital initiation. METHODS Among patients hospitalized for newly diagnosed HFrEF in the Get With The Guidelines-Heart Failure registry from 2016 to 2023, eligibility criteria based on regulatory labeling, guidelines, and expert consensus documents were applied for angiotensin receptor-neprilysin inhibitor, beta-blocker, mineralocorticoid receptor antagonist, and sodium-glucose cotransporter 2 inhibitor therapies. Of those eligible, the projected effect of quadruple therapy on 12-month mortality was modeled using treatment effects from pivotal clinical trials utilized by the AHA/ACC/HFSA Guideline for the Management of Heart Failure, and compared with observed outcomes among patients treated with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and beta-blockers. RESULTS Of 33,036 patients newly diagnosed with HFrEF, 27,158 (82%) were eligible for quadruple therapy, and 30,613 (93%) were eligible for ≥3 components. From 2021 to 2023, of patients eligible for quadruple therapy, 15.3% were prescribed quadruple therapy and 41.5% were prescribed triple therapy. Among Medicare beneficiaries eligible for quadruple therapy, 12-month incidence of mortality was 24.7% and HF hospitalization was 22.2%. Applying the relative risk reductions in clinical trials, complete implementation of quadruple therapy by time of discharge was projected to yield absolute risk reductions in 12-month mortality of 10.4% (number needed to treat = 10) compared with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and beta-blocker, and 24.8% (number needed to treat = 4) compared with no GDMT. CONCLUSIONS In this nationwide U.S. cohort of patients hospitalized for newly diagnosed HFrEF, >4 of 5 patients were projected as eligible for quadruple therapy at discharge; yet, <1 in 6 were prescribed it. If clinical trial benefits can be fully realized, in-hospital initiation of quadruple medical therapy for newly diagnosed HFrEF would yield large absolute reductions in mortality.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Jacob B Pierce
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sabra C Lewsey
- Division of Cardiovascular Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Clyde W Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brooke Alhanti
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Harriette G C Van Spall
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, California, USA.
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Kittipibul V, Vaduganathan M, Ikeaba U, Chiswell K, Butler J, DeVore AD, Heidenreich PA, Huang JC, Kittleson MM, Joynt Maddox KE, Linganathan KK, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Fonarow GC, Greene SJ. Cause-Specific Health Care Costs Following Hospitalization for Heart Failure and Cost Offset With SGLT2i Therapy. JACC. HEART FAILURE 2024; 12:1409-1421. [PMID: 38727651 DOI: 10.1016/j.jchf.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND Little is known regarding differences in cause-specific costs between heart failure (HF) with ejection fraction (EF) ≤40% vs >40%, and potential cost implications of sodium glucose co-transporter 2 inhibitor (SGLT2i) therapy. OBJECTIVES This study sought to compare cause-specific health care costs following hospitalization for HF with EF ≤40% vs >40% and estimate the cost offset with implementation of SGLT2i therapy. METHODS This study examined Medicare beneficiaries hospitalized for HF in the Get With The Guidelines-Heart Failure registry from 2016 to 2020. Mean per-patient total (excluding drug costs) and cause-specific costs from discharge through 1-year follow-up were calculated and compared between EF ≤40% vs >40%. Next, risk reductions on total all-cause and HF hospitalizations were estimated in a trial-level meta-analysis of 5 pivotal trials of SGLT2is in HF. Finally, these relative treatment effects were applied to Medicare beneficiaries eligible for SGLT2i therapy to estimate the projected cost offset with implementation of SGLT2i, excluding drug costs. RESULTS Among 146,003 patients, 50,598 (34.7%) had EF ≤40% and 95,405 (65.3%) had EF >40%. Mean total cost through 1 year was $40,557. Total costs were similar between EF groups overall but were higher for EF ≤40% among patients surviving the 1-year follow-up period. Patients with EF >40% had higher costs caused by non-HF and noncardiovascular hospitalizations, and skilled nursing facilities (all P < 0.001). Trial-level meta-analysis of the 5 SGLT2i clinical trials estimated 11% (rate ratio: 0.89; 95% CI: 0.84-0.93; P < 0.001) and 29% (rate ratio: 0.71; 95% CI: 0.66-0.76; P < 0.001) relative reductions in rates of total all-cause and HF hospitalizations, respectively, regardless of EF. Reductions in all-cause and HF hospitalizations were projected to reduce annual costs of readmission by $2,451 to $2,668 per patient with EF ≤40% and $1,439 to $2,410 per patient with EF >40%. CONCLUSIONS In this large cohort of older U.S. adults hospitalized for HF, cause-specific costs of care differed among patients with EF ≤40% vs >40%. SGLT2i significantly reduced the rate of HF and all-cause hospitalizations irrespective of EF in clinical trials, and implementation of SGLT2i therapy in clinical practice is projected to reduce costs by $1,439 to $2,668 per patient over the 1 year post-discharge, excluding drug costs.
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Affiliation(s)
- Veraprapas Kittipibul
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Karen Chiswell
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | | | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Karen E Joynt Maddox
- Cardiology Division, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | | | | | - Anjali Tiku Owens
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pamela N Peterson
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA; Department of Medicine, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Scott D Solomon
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System and University of Minnesota, Minneapolis, Minnesota, USA
| | - Clyde W Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California-Los Angeles, Los Angeles, California, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA.
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Khan MS, Fonarow GC, Greene SJ. Guideline-directed medical therapy for heart failure: The key ingredient for successful in-hospital and post-discharge care. Eur J Heart Fail 2024; 26:355-358. [PMID: 38291014 DOI: 10.1002/ejhf.3152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 02/01/2024] Open
Affiliation(s)
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, CA, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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