Initiation of novel guideline-directed medical therapies (GDMTs) for patients with heart failure (HF) is delayed compared with other GDMTs, and few patients received target doses of GDMTs requiring uptitration, according to an article published Oct. 12 in JACC: Heart Failure.

Gianluigi Savarese, MD, et al., conducted a multinational, observational cohort study using routine-care databases to find patterns of the use of GDMTs after hospitalization for HF in the real world. The data included 266,589 patients from Japan, Sweden and the U.S. who had been hospitalized for HF and newly introduced to GDMT in the prior 12 months.

Results showed that initiation of novel GDMT was delayed compared with other GDMTs, that few patients received the target dose, and that there were high discontinuation rates across all three countries. In addition, the mean time from hospitalization for HF and GDMT initiation were longer for novel GDMTs (dapagliflozin or sacubitril/valsartan) than for other GDMTs: 33 and 19 vs. 18 to 24 days (U.S.), 39 and 44 vs. 12 to 13 days (Japan), 44 and 33 vs. 22 to 31 days (Sweden).

The GDMT with the highest percentage of discontinuation was MRAs (42.2%), followed by (ACE inhibitors (38.4%), ARBs (33.4%), sacubitril/valsartan (26.4%), beta-blockers (25.2%) and dapagliflozin (23.5%). Additionally, the target dose was frequently achieved for dapagliflozin (75.7%), likely due to not needing uptitration. On the other hand, the target dose for the other drugs was significantly lower; corresponding achievements were 5.1%, 20.1%, 6.7%, 28.2% and 7.2%, respectively.

The authors note that “despite the paradigm-shifting trial results for novel GDMTs, early initiation of novel GDMTs in real-world settings remains a clinical challenge.” For example, GDMT delay was generally more in patients with vs. without comorbidities, such as kidney disease and type 2 diabetes, even though novel GDMTs are especially important in patients with chronic kidney disease and diabetes.

In an accompanying editorial comment, Ankeet S. Bhatt, MD, MBA, SM, and Justin J. Slade, MD, note that the authors “should be commended on providing a detailed and current understanding of how clinicians and patients are prioritizing therapeutic optimization in HF”. They go on to say that the study illustrates the importance of improving implementation and care delivery that strives to better achieve optimal medical therapy for patients.

Keywords: Renal Insufficiency, Chronic, Hospitalization, Valsartan, Sweden, Japan, Pharmaceutical Preparations, Diabetes Mellitus, Type 2, Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, United States

< Back to Listings