Results:

This analysis included 3,518 patients from 150 primary care and cardiology practices. The mean age of this cohort was 66 ± 13 years, 29% were female, and mean EF was 29 ± 8%. The investigators found that among eligible patients, 27%, 33%, and 67% were not prescribed ACEI/ARB/ARNI, beta-blocker, and MRA therapy, respectively. When medications were prescribed, few patients were receiving target doses of ACEI/ARB (17%), ARNI (14%), and beta-blocker (28%), whereas most patients were receiving target doses of MRA therapy (77%). Among patients eligible for all classes of medication, 1% were simultaneously receiving target doses of ACE/ARB/ARNI, beta-blocker, and MRA. In adjusted models, older age, lower blood pressure, more severe functional class, renal insufficiency, and recent HF hospitalization generally favored lower medication utilization or dose. Social and economic characteristics were not independently associated with medication use or dose.

Compared with patients receiving <50% target dose, patients not receiving ACEI/ARB therapy tended to be older with similar blood pressure and worse renal function. Patients receiving <50% target ARNI dose tended to have similar renal function, but lower blood pressure than those not receiving therapy. Compared with patients receiving <50% target dose, patients not receiving beta-blockers tended to be older and were more likely to be female, white, and have a history of asthma or chronic obstructive pulmonary disease (COPD), but less likely to have prior HF hospitalization. Compared with patients receiving target doses, patients not receiving MRA therapy were more likely to be older, white, male, and have worse renal function. Female sex, chronic renal insufficiency, atrial fibrillation, and New York Heart Association functional class III/IV symptoms were strong independent factors associated with not being prescribed an ACEI/ARB (all p ≤ 0.007). For ARNI therapy, multiple clinical factors were independently associated with lower likelihood of treatment, including older age, Hispanic ethnicity, chronic renal insufficiency, and higher EF (all p ≤ 0.009). Increasing age, asthma/COPD, atrial fibrillation, and lower EF were associated with not receiving beta-blocker therapy (all p ≤0.016), whereas a history of chronic renal insufficiency was associated with greater likelihood of beta-blocker treatment (p = 0.045). Characteristics that were independently associated with not receiving MRA therapy included Hispanic ethnicity, older age, and chronic renal insufficiency (all p ≤ 0.029).