Global Disparities in Prescribing HFrEF Medications

Quick Takes

  • In a large global cohort of patients with HFrEF discharged from an acute HF hospitalization, use of guideline-recommended medications was suboptimal.
  • Use of HFrEF medical therapy was notably lower for women, patients from low-income countries, and patients without health insurance.

Study Questions:

In a global cohort of patients with heart failure with reduced ejection fraction (HFrEF), how do prescription rates and achieving target medication doses of guideline-recommended therapies vary with respect to country income level and patient insurance status?


This analysis used data from the REPORT-HF study, which was a prospective, observational, global (six continents, 44 countries, 358 sites) cohort study of patients hospitalized with a primary diagnosis of acute heart failure (HF). Patient demographics, hospital data, and post-discharge follow-up information were collected. Information on prescribed HF medications and percent of target doses was collected at discharge and 6 months. Specifically, renin–angiotensin system (RAS) inhibitors, beta-blockers, and mineralocorticoid receptor antagonists (MRAs) were assessed for this study. Clinical follow-up was conducted at 6 and 12 months. Association between guideline-recommended treatment and 1-year mortality was also studied.


The REPORT-HF study period was from July 2014–March 2017. A total of 18,553 patients were enrolled; of these patients, 8,669 had HFrEF and survived to discharge (1,458, 3,363, and 3,848 patients from low-, middle-, and high-income countries, respectively). This subset of patients was included in this study.

At discharge, only 37% of patients were on all three classes of HFrEF medications, with a large difference seen between low- and high-income countries (19% vs. 41%). Similarly, only 34% of patients were on the three classes of medications at 6 months, with a large difference between low- and high-income countries (15% vs. 37%). Patients from low-income countries also had less titration of RAS inhibitors and beta-blockers during this 6-month period. Patients without health insurance compared to those with insurance also had lower rates of guideline-recommended HF therapies and were less likely to have medications titrated to target doses. In multivariable analysis, lower guideline-recommended HF medication use was noted for women, older patients, and patients without health insurance; from low-income countries; and with a history of chronic kidney disease.

Overall, 1-year mortality was 22%. Mortality was higher for low- compared to high-income countries (25% vs. 19%). Not being on any HFrEF guideline-recommended therapy at discharge was associated with a high 1-year mortality at 31%. Survival was best for patients on at least 50% of target doses for these HF medications, which was seen across all country income levels.


In a global cohort study of patients with HFrEF discharged from an acute HF hospitalization, use of guideline-recommended drug therapies was low at discharge and at 6 months; this was worse for patients from low-income countries and without health insurance.


Treatment of HFrEF remains a challenge globally. Despite having an increasing number of medications proven to reduce morbidity and mortality, there are many barriers to adequate implementation. This study demonstrates that this issue extends across the world, highlighting overall underuse and subtarget dosing of HFrEF medications and large disparities that exist for large populations of patients based on gender, country income level, and insurance status. While there are limitations to this study that can lead to confounding (such as lack of information on adverse drug reactions, medication adherence, medication contraindications), this study can still be seen as a call to action to implement large-scale strategies and policies to improve HFrEF management. Use of sodium-glucose cotransporter-2 inhibitors was not included given the enrollment period, but this will likely face similar implementation challenges globally given its high cost.

Clinical Topics: Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure

Keywords: Adrenergic beta-Antagonists, Developed Countries, Developing Countries, Heart Failure, Insurance Coverage, Insurance, Health, Medication Adherence, Mineralocorticoid Receptor Antagonists, Patient Discharge, Prescriptions, Renal Insufficiency, Chronic, Renin-Angiotensin System, Secondary Prevention, Socioeconomic Factors, Stroke Volume

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