Many patients with HFrEF eligible for quad therapy at discharge; SGLT2 inhibition lacking
Key takeaways:
- Quadruple therapy feasible in nearly half of patients with HFrEF at discharge after a decompensated event.
- Initiation of at least two guideline-recommended therapies significantly reduced rehospitalization.
Quadruple therapy after discharge was feasible for a large proportion of patients with HF reduced ejection fraction, yet few were prescribed the “four pillars” of HFrEF therapy, researchers in Italy reported.
Prescription of at least two of the four guideline-recommended pillars of HFrEF therapy was associated with an approximately 82% reduced risk for 30-day rehospitalization, according to a study published in the Journal of the American Heart Association.
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Additionally, nearly three-quarters of patients were eligible for SGLT2 inhibitors, but few were prescribed them.
“Current guidelines recommend that patients HFrEF should receive a quadruple therapy with an ACE inhibitor or an angiotensin receptor blocker or an angiotensin receptor-neprilysin inhibitor (ARNI), a beta-blocker, a mineralocorticoid receptor antagonist (MRA), and a SGLT2 inhibitor,” Domenico D’Amario, MD, PhD, of the department of translational medicine at Università del Piemonte Orientale in Padiglione, Italy, and colleagues wrote. “There is emerging consensus that rapid sequencing or simultaneous initiation of the four pharmacological pillars confers higher protection to patients. ... Because the ‘four pillars’ showed meaningful benefits within almost 4 weeks after initiation, providing patients with an early and comprehensive protection is key to improve clinical outcomes.”
D’Amario and colleagues conducted the present retrospective study to evaluate predictors of the number of HF pillars prescribed at discharge and the subsequent risk for rehospitalization.
In 2019, researchers at Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome previously implemented the Gemelli Heart Failure Data Mart to collect clinical data of patients with HF treated at Policlinico A. Gemelli.
Using this data mart and an automated approach, 305 consecutive patients with HFrEF were selected and categorized based on the number and type of HF therapies prescribed at hospital discharge (median age, 73 years; 74% men).
Pillars of HFrEF therapy used in clinical practice
Overall, 1.6% of patients received no pillar of HFrEF therapy at discharge, 25% received one, 49.2% received two, 21.6% received three and 2.6% were on all four pillars at discharge.
Patients treated with a higher number of drugs were younger and had a higher estimated glomerular filtration rate. Patients on a lower number of drugs presented with higher N-terminal pro-B-type natriuretic peptide values and worse renal function, according to the study.
With regard to current recommendations and absence of contraindications, D’Amario and colleagues reported that simultaneous initiation of all four pillars of therapy was feasible in 46.2% of patients.
Most patients on dual therapy were taking a beta-blocker on top of an ACE inhibitor, angiotensin receptor blocker or ARNI, representing 40.3% of the overall population, whereas patients on triple therapy with an MRA represented 20%, according to the study.
SGLT2 inhibition was considered appropriate in 75.4% of patients; however, 71.1% of the cohort were eligible for an SGLT2 inhibitor but were not prescribed one.
Predictors and outcomes of nonuse
Renal insufficiency was an independent predictor of less than two pillars of HFrEF therapy prescribed (adjusted OR = 0.16; 95% CI, 0.08-0.32) and renal insufficiency, hypotension and elevated age were predictors of not receiving an ACE inhibitor, angiotensin receptor blocker or ARNI, according to the study.
After adjusting for age and renal function, the researchers reported that patients receiving two or more pillars at discharge had approximately 82% lower risk for 30-day HF rehospitalization (aOR = 0.18; 95% CI, 0.06-0.57) compared with patients assigned fewer pillars of HFrEF therapy.
“Discharge from an acute decompensation event offers a safe and valuable opportunity for the simultaneous initiation of the four foundational treatments in heart failure with reduced ejection fraction,” the researchers wrote. “Simultaneous initiation of four treatments may have an impact on reducing rehospitalization within the vulnerable phase after discharge, prompting ad hoc pragmatic trials testing this strategy.”
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