Log in to MyACC
Differences in Heart Failure Outcomes in the US and Canada
Quick Takes
- Differences in outcomes between HFrEF patients in US and Canada were driven by increased heart failure hospitalization among US Black patients.
- This is an important study because it suggests that poorer outcomes in the US are probably, in part, due to suboptimal utilization of maximum tolerated doses of GDMT in the minority population.
- Keeping health equity in mind, these findings should prompt the writers of ACC/AHA heart failure guidelines to recommend a strategy tailored to the needs of the minority population in the US.
Study Questions:
What are the patterns of care and clinical outcomes among patients with heart failure with reduced ejection fraction (HFrEF) in the United States and Canada?
Methods:
The study cohort comprised a total of 894 patients with HFrEF (EF ≤40%), who were enrolled in the GUIDE-IT (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment) trial at 45 sites across the United States and Canada. Of the 894 patients included in this analysis, 756 were enrolled at sites in the United States and 138 were enrolled at sites in Canada. Kaplan-Meier survival estimates stratified by country of enrollment were developed for the trial outcomes, and log-rank testing was compared between the groups. The study authors also compared guideline-directed medical therapy (GDMT) use and titration.
Results:
US patients were more likely to be younger, to be Black, to have higher body mass index, and to have histories of defibrillator placement or sleep apnea. Utilization of beta-blockers was significantly higher in Canada at baseline (99.3% vs. 94.0%; p = 0.01) and 6 months (99.0% vs. 94.1%; p = 0.04), and use of mineralocorticoid receptor antagonists was higher in Canada at 6 months (68.3% vs. 55.1%; p = 0.01). Canadian patients were less likely to experience the primary study endpoint of cardiovascular death and HF hospitalization (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.45-0.93; p = 0.01) due to decreased rates of HF hospitalization (HR, 0.57; 95% CI, 0.38-0.86; p = 0.003). The differences in outcomes were driven by increased HF hospitalization among US Black patients. All-cause mortality (HR, 0.85; 95% CI, 0.53-1.36; p = 0.80) and cardiovascular mortality (HR, 0.95; 95% CI, 0.56-1.61; p = 0.66) were similar between the countries after adjustment. There were also no differences in the composite endpoint of all-cause mortality or hospitalization for any cause. Natriuretic-guided therapy did not result in different clinical outcomes from the usual-care arm in either the United States or Canada.
Conclusions:
The study authors concluded that in GUIDE-IT, patients with HFrEF in Canada were significantly less likely to be hospitalized for HF. They opined that differences in GDMT use, along with differences in socio-demographics and care delivery structures, may contribute to these differences, highlighting the importance of increasing diversity in clinical trials.
Perspective:
This is an important study because it suggests that poorer outcomes in the US are probably, in part, due to suboptimal utilization of maximum tolerated doses of GDMT in the minority population. Keeping health equity in mind, these findings should prompt the writers of American College of Cardiology/American Heart Association (ACC/AHA) HF guidelines to recommend a strategy tailored to the needs of the minority population in the US.
Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Sleep Apnea
Keywords: Adrenergic beta-Antagonists, African Americans, Biomarkers, Body Mass Index, Defibrillators, Diuretics, Heart Failure, Maximum Tolerated Dose, Mineralocorticoid Receptor Antagonists, Natriuretic Peptide, Brain, Outcome Assessment, Health Care, Sleep Apnea Syndromes, Stroke Volume, Ventricular Dysfunction, Left
< Back to Listings
