Medical Therapy for HFrEF: CHAMP-HF Registry

Study Questions:

What are the patterns and factors associated with use and dose of heart failure with reduced ejection fraction (HFrEF) medications in current practice?

Methods:

The study cohort was comprised of subjects from the CHAMP-HF (Change the Management of Patients With Heart Failure) registry, which included outpatients in the US with chronic HFrEF receiving at least one oral medication for management of HF. The study authors characterized patients by baseline use and dose of guideline-directed medical therapy (GDMT) including angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor neprilysin inhibitor (ARNI), beta-blocker, and mineralocorticoid receptor antagonist (MRA). They explored patterns of GDMT use and dosing, the clinical and social patient profiles associated with GDMT use, and the patient-level factors associated with medication use and target dosing.

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).

Conclusions:

The study authors concluded that significant gaps in use and dose of GDMT remain.

Perspective:

This contemporary study has identified several important factors to improve use and target dosing of GDMT in HFrEF patients.

Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers

Keywords: Adrenergic beta-Antagonists, Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Atrial Fibrillation, Blood Pressure, Geriatrics, Heart Failure, Mineralocorticoid Receptor Antagonists, Neprilysin, Pulmonary Disease, Chronic Obstructive, Renal Insufficiency, Chronic, Stroke Volume


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