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Optimal Medical Therapy and Outcomes in Chronic HFrEF
Quick Takes
- In a multicenter cohort of chronic HFrEF patients, only 50% of patients were on optimal therapy as defined by the optimal medical therapy (OMT) score that is based on receipt of beta-blocker, ACEI/ARB/ARNI, and MRA at appropriate target doses.
- Patients receiving optimal therapy as defined by the OMT score had the lowest hazard for all-cause and CV death and this benefit was more prominent among patients aged ≥65 years.
- Patient factors associated with receiving optimal therapy were younger age, lower comorbidity burden, and receiving care at dedicated HF clinics.
Study Questions:
What are the outcomes in patients with chronic heart failure and reduced ejection fraction (HFrEF) as determined by their optimal medical therapy (OMT) score?
Methods:
The authors used the CHAMP-HF (Change the Management of Patients with Heart Failure) registry with chronic HFrEF patients with left ventricular EF ≤40% and were receiving ≥1 oral therapy for HF across 150 US sites. An OMT score was calculated based on sum of points for each medication class (HF-specific beta-blocker [BB]; angiotensin-converting enzyme inhibitor [ACEI], angiotensin receptor blocker [ARB], or angiotensin receptor-neprilysin inhibitor [ARNI]; and mineralocorticoid receptor antagonist [MRA]), accounting for use and dose (<50% or ≥50% maximal target dose for BB/ACEI/ARB/ARNI). OMT scores were classified as suboptimal (on no HF-specific BB or ACEI/ARB/ARNI), acceptable, or optimal (on HF-specific BB and ACEI/ARB/ARNI). Endpoints of interest included all-cause death, cardiovascular (CV) death, HF hospitalization, and composite of CV death and HF hospitalization at 2 years.
Results:
The final study cohort was comprised of 4,582 patients with 24 months of follow-up. Median age was 68 years, 29% were female, and 62% were White. The optimal group had 50% of patients, acceptable 14%, and suboptimal 35%. Compared with the suboptimal therapy group, the optimal therapy group had the lowest hazard for all-cause death (hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.64-0.92) and CV death (HR, 0.79; 95% CI, 0.65-0.96). There were no differences in HF hospitalizations across the three groups. The hazard for all-cause death was no different in the acceptable therapy group compared with the suboptimal therapy group (HR, 0.94; 95% CI, 0.73-1.20). Reduced hazard for all-cause mortality was lower for patients ≥65 years old in optimal therapy compared with the suboptimal group but not in patients ≤65 years. Patient characteristics associated with higher OMT scores were younger age, non-Hispanic White race, lower comorbidity burden including chronic kidney and lung disease, higher Kansas City Cardiomyopathy Questionnaire score, hypertension, and receiving care from dedicated HF clinics.
Conclusions:
In a retrospective cohort analysis of approximately 5,000 patients with chronic HFrEF, only 50% of patients received optimal therapy as defined by use of BB and ACEi/ARB/ARNI at any dose. The optimal therapy group had the lowest hazard for all-cause and CV mortality and this benefit was more prominent for patients aged ≥65 years.
Perspective:
Data showing benefit with optimal therapy in HFrEF are overwhelming. These data suggest that apart from combination therapy with BB, angiotensin antagonists, MRA, and sodium-glucose cotransporter-2 inhibitor, titrating these agents to target doses is also important. This study demonstrates an association between the proposed OMT score and outcomes and suggests that higher OMT scores correlate with lower risk for all-cause death and CV mortality. While these findings are not surprising given extensive data already exist on benefits of combination therapy for HF, it does lend validity to the OMT score that can help guide clinical management in real-world practice. Other noteworthy findings include higher scores in patients treated at HF clinics, showing the importance of site-level factors that can be modified. In addition, while older patients were less likely to receive optimal therapy, benefits of optimal therapy were larger in individuals ≥65 years, suggesting that this subgroup perhaps should be targeted to encourage use of optimal therapy.
Clinical Topics: Heart Failure and Cardiomyopathies
Keywords: Heart Failure, Reduced Ejection Fraction, Pharmaceutical Preparations, Treatment Outcome
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