Only a small proportion of US patients hospitalized for heart failure with reduced ejection fraction who were eligible for guideline-recommended quadruple medical therapy received all four drug classes at hospital discharge, according to a study in JAMA Cardiology.
Among older patients discharged on quadruple medical therapy, 19% died within 1 year and 37% experienced death or heart failure rehospitalization, based on linked registry and Medicare data. Median per-patient health care expenditures during the same period approached $28,000, reflecting a substantial residual clinical and economic burden.
Researchers conducted a retrospective cohort study using data from the American Heart Association Get With The Guidelines–Heart Failure registry linked to fee-for-service Medicare claims. The analysis included patients aged 65 years or older hospitalized for heart failure with reduced ejection fraction (HFrEF), defined as a left ventricular ejection fraction of 40% or lower, who were discharged alive between July 1, 2021, and December 31, 2023. To identify patients medically eligible for comprehensive therapy, the researchers excluded those with documented contraindications to angiotensin receptor–neprilysin inhibitors, beta-blockers, mineralocorticoid receptor antagonists, or sodium-glucose cotransporter 2 inhibitors, as well as patients with prior dialysis, heart transplant, or left ventricular assist device implantation, discharge to hospice, or transfer to another acute care facility. The exposure of interest was prescription of all four medication classes at any dose at hospital discharge.
Among 20,651 eligible patients treated across 532 US hospitals, 1,490 patients (7.2%) were prescribed quadruple medical therapy at discharge, with marked between-hospital variation. The median age of treated patients was 74 years, 36% were women, and the median ejection fraction was 26%. Prespecified outcomes included all-cause mortality, heart failure hospitalization, and the composite of mortality or heart failure hospitalization, assessed as time to first event. Health care expenditures were calculated from unadjusted Medicare Part A and B payments and standardized to 2023 US dollars.
“Patients hospitalized for HFrEF in US clinical practice are at very high risk of poor clinical outcomes, even when prescribed quadruple medical therapy,” noted lead author Stephen J. Greene, MD, of the Duke Clinical Research Institute, Durham, North Carolina, and colleagues.
During 12 months of follow-up, cumulative incidences were 19% for all-cause mortality, 26% for heart failure hospitalization, and 37% for the composite outcome, while 55% of patients experienced at least one all-cause hospitalization. Median estimated survival declined with advancing age, ranging from 7.4 years among patients aged 65 to 69 years to 3.1 years among those aged 85 to 89 years.
The researchers identified several limitations. The study was limited to Medicare beneficiaries aged 65 years or older, and absolute risks may differ in younger populations. Median survival estimates were derived using a Weibull distribution with a maximum observed follow-up of 3 years, requiring extrapolation for younger age groups. In addition, medication adherence, persistence, and dose titration following discharge could not be assessed, and the contribution of intolerance or access barriers to observed outcomes remains uncertain.
Several researchers reported financial relationships with pharmaceutical or medical device companies, including consulting fees, research support, employment, or stock ownership, while the Get With The Guidelines–Heart Failure program is provided by the American Heart Association and sponsored in part by industry partners, none of whom had a role in the study design, conduct, analysis, or reporting.
Source: JAMA Cardiology
