Teng THK, et al. - The first prospective multinational data from Asia on prescribing patterns of guideline-directed medical therapies for the management of patients with heart failure and reduced ejection fraction (HFrEF) was examined to assess their effects on outcomes. Findings indicated underutilization of guideline-directed medical therapies at recommended doses in patients with HFrEF. This suggests the necessity for improved uptake and uptitration of these therapies to achieve better patient outcomes.

Methods

• Patients aged 18 years or older with symptomatic heart failure (stage C, with at least one episode of decompensated heart failure in the past 6 months that resulted in admission to hospital or was treated in an outpatient clinic) and left ventricular systolic dysfunction (ejection fraction ≤40% on baseline echocardiography, consistent with 2016 European Society of Cardiology guidelines) were enrolled in this ASIAN-HF registry (with enrolment from 46 centers in 11 countries in Asia).
• Patients were excluded if they had heart failure caused by severe valvular heart disease, life-threatening comorbidity with a life expectancy of less than 1 year, or had concurrent participation in a clinical trial or were unable or unwilling to give consent.
• For the outcomes of death and cause-specific admittance to hospital, researchers followed up the patients for 3 years.
• Uptake of guideline-directed medical therapies (as proportions) by therapeutic class, achieved doses as proportions of guideline-recommended doses, and their association with 1-year composite outcome of all-cause death or admittance to hospital because of heart failure were assessed as the primary outcomes.

Results

• Researchers recruited 5,276 patients with HfrEF from October 1, 2012 to December 31, 2015.
• Mean age of the patients was 59.6 years (SD 13.2); 77% were men; body-mass index: 24.9 kg/m² (5.1), 33% New York Heart Association class III or IV.
• For this study, they identified 5,061 eligible patients taking medication for heart failure; of these, 4,544 (90%) had follow-up data available, with median follow-up of 417 days (IQR 214–735).
• Prescription of ACE inhibitors or ARBs was made for 3,868 (77%) of 5,005 patients, β blockers for 3,975 (79%) of 5,061, and MRAs for 2,998 (58%) of 5,205; wide regional variation in prescriptions was identified.
• In only 17% of cases for ACE inhibitors or ARB, 13% for β blockers, and 29% for MRAs were guideline-recommended doses achieved.
• Attainment of guideline-recommended dose was noted in association with country (all three drug classes), increasing body-mass index (ACE inhibitors or ARBs and MRAs), and in-patient recruitment (ACE inhibitors or ARBs and β blockers) (all p < 0.05).
• When adjusted for indication bias, hazards of a 1-year composite outcome for ACE inhibitors or ARBs and β blockers were lower, compared with non-users, in association with increasing drug doses, from low dose (1–<25% of guideline-recommended dose) upwards.
• The group that attained guideline-recommended doses above 50% showed the lowest adjusted hazards (hazard ratio [HR] 0.54, 95% CI 0.50–0.58 for ACE inhibitors or ARBs [50–99.9%]; HR 0.47, 0.46–0.50 for β blockers, and HR 0.77, 0.72–0.81 for MRAs [≥100%]).