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Target Doses of Heart Failure Medical Therapy and Blood Pressure
Study Questions:
Is blood pressure a barrier to achieving targeted doses of heart failure with reduced ejection fraction (HFrEF) therapy?
Methods:
The study cohort was comprised of systolic HF patients enrolled in the CHAMP-HF (Change the Management of Patients With Heart Failure) registry without documented intolerance to angiotensin-converting enzyme inhibitors (ACEIs), angiotensin-receptor blockers (ARBs), angiotensin receptor-neprilysin inhibitors (ARNIs), and beta-blockers (BBs). The study authors estimated the proportion receiving target doses (% of target dose, 95% confidence interval [CI]) based on the most recent American College of Cardiology/American Heart Association/Heart Failure Society of America heart failure guidelines at baseline in all patients, and by systolic blood pressure (SBP) category (≥110 vs. <110 mm Hg). The author-conducted sensitivity analysis was using the following SBP cut-points (100, 120, and 130 mm Hg) to examine the effects on the results. An additional sensitivity analysis excluded those with heart rate <60 bpm because bradycardia may be a reason for nonintensification of BB. The chi-square test was used to compare the proportion of medication classes across SBP groups.
Results:
The final cohort in this report comprised the 3,095 patients eligible for analysis; 2,421 (78.2%) had SBP ≥110 mm Hg. BB use was lower (81.9% vs. 85.6%; p = 0.03), ARB use was higher (22.6% vs. 14.7%; p < 0.0001), ARNI use was lower (11.6% vs. 17.5%; p < 0.0001), and ACEI use was similar (41.0% vs. 42.4%; p = 0.50) in patients with SBP ≥110 mm Hg compared with those with SBP <110 mm Hg. The proportion of patients receiving target doses were 18.7% (95% CI, 17.3%-20.0%; BB), 10.8% (95% CI, 9.7%-11.9%; ACEI/ARB), and 2.0% (95% CI, 1.5%-2.5%; ARNI). Among those with SBP <110 mm Hg (n = 674), 17.5% (95% CI, 14.6%-20.4%; BB), 6.2% (95% CI, 4.4%-8.1%; ACEI/ARB), and 1.8% (95% CI, 0.8%-2.8%; ARNI) were receiving target doses. Among those with SBP ≥110 mm Hg (n = 2,421), 19.0% (95% CI, 17.4%-20.6%; BB), 12.1% (95% CI, 10.8%-13.4%; ACEI/ARB), and 2.0% (95% CI, 1.5%-2.6%; ARNI) were receiving target doses. Despite a majority of the cohort (52.3%) receiving both a BB and an ACEI/ARB/ARNI, the proportion of patients receiving target doses of both types of medication (beta-blockade and angiotensin inhibition) was only slightly higher among those with SBP ≥110 mm Hg (9.7%) compared with those having a SBP <110 mm Hg (5.8%).
Conclusions:
The study authors concluded that <20% of chronic HFrEF patients eligible for treatment with BBs and ACEI/ARB/ARNI, were receiving target doses, even among those with SBP ≥110 mm Hg.
Perspective:
This is an important study because it suggests that there is a significant opportunity to improve therapy of chronic HFrEF patients, particularly when <1 in 10 patients was optimally treated with target doses of guideline-directed medical therapy (GDMT). It will not be surprising if Centers for Medicare & Medicaid Services makes achieving target doses of GDMT in chronic HFrEF an important quality metric for physician compensation in the not too distant future given the mortality and morbidity benefits of dose intensification.
Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Implantable Devices, Acute Heart Failure, Heart Failure and Cardiac Biomarkers
Keywords: Adrenergic beta-Antagonists, Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Blood Pressure, Blood Pressure Determination, Bradycardia, Geriatrics, Heart Failure, Heart Rate, Neprilysin, Primary Prevention, Receptors, Angiotensin, Stroke Volume, Systole
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