Doing Our Part to Get with the Heart Failure Guidelines

Heart failure (HF) is a common and highly morbid condition that impacts more than 65 million patients worldwide, including more than 6 million patients in the United States, and leads to more than 30 billion in annual healthcare spending (1). One of the most important tools we have as clinicians to improve outcomes in this disease is the use of highly-effective guideline-directed medical therapy (GDMT) using clinical trial-proven medications. However, a number of prior studies have demonstrated that use of GDMT is suboptimal; the CHAMP-HF registry showed that <1% of patients at 12 months of follow-up were on target doses of all three medication classes (2).

One facet of GDMT delivery that has been less-well understood is where and when these medications should be initiated and titrated. In this issue of JACC Heart Failure, Swat et al examine this important question using inpatient data. As previously demonstrated, HF hospitalizations are a critical opportunity for medical intervention for patients as prior studies have shown high risk of death and readmission at 30 days and initiation of GDMT for heart failure has been shown to reduce mortality and recurrent HF hospitalization (3). In this issue of JACC Heart Failure, using the American Heart Association’s Get With The Guidelines-Heart Failure (GWTG-HF) Registry, Swat et al describe clear opportunities for improvement from an inpatient provider standpoint for initiation of GDMT among the subset of HF patients with left ventricular dysfunction. The authors studied a population of patients with heart failure with reduced ejection fraction (HFrEF) from 2017 to 2020 using data collected from 160 US institutions accounting for over 50,000 patients. This study assessed prescribing rates of medical therapy for HF prior to, during and following hospitalization for decompensated HF.

The authors found that on average during a HF hospitalization, one evidence-based medication was added per patient, and this resulted in on average 32,8%, or roughly 1 in 3 patients receiving all indicated medications on hospital discharge (compared to 14.9%, or roughly 1 in 6 on admission). Further, during the study period from 2017 to 2020, there was a statistically significant overall increase in medication initiation, with an odds ratio for new initiation of evidence-based HF therapies of 1.08 per quarter-year during the study period.

There are positive takeaways from this study. For example, the authors found an increase in prescription rates for all four drug classes from admission to discharge (beta blockers 69.9% to 97.7%, ACE/ARB/ARNI 59% to 91.2%, mineralocorticoid receptor antagonists 26.2% to 55.9%, hydralazine/nitrates 15.5% to 27.4%), suggesting that initiation of these medications during hospitalization was feasible and, at least for some medications, reliably undertaken. Additionally, the overall increase in GDMT initiation during HF hospitalization the authors noted during the study period is encouraging, given the dire need for improved outcomes in this population.

However, there are also takeaways that can focus us more closely on some key areas for improvement. For example, women were less likely to have appropriate initiation of HF medical therapy during hospitalization (odds ratio 0.88, p < 0.001). These results confirm prior reports of a key gap in treatment for heart failure patients as women are much less like to be initiated on HF medical therapy while hospitalized and in the outpatient setting (4). Prior studies for example have shown decreased rates of ACE/ARB prescriptions for women when compared with men (5). This represents a key quality improvement opportunity given that female HFrEF patients have worse health status compared with male patients (6).

From a healthcare access standpoint, differences in urban vs rural hospital delivery of HF medical therapy represents an additional area of focus for improvement. The GWTG participants are enriched for teaching hospitals (85.7%) and urban/suburban locale (97.4%) compared to the broader population of hospitals across the U.S., but rural hospitals’ performance was significantly worse than urban/suburban ones, with an odds ratio for medication initiation of 0.6 (p=0.017). While comprising only 2.6% of this study population, rural hospitals make up roughly one-third of general acute-care hospitals in this country. Rural hospitals therefore represent a key source of health disparity in this country in a broader sense, and the context within which these findings should be considered is even more challenging. Mortality from cardiovascular disease is higher in rural compared to urban areas possibly due to differences in access to care, social determinants of health and quality of care delivery. Further studies are therefore necessary to understand how to augment prescription prescribing behavior for rural inpatient providers to meet this treatment gap.

Lastly, this study is also notable for who isn’t included in its pages. The performance numbers reported here are limited to hospitals participating in the Get With the Guidelines program through the AHA. It therefore does not necessarily represent practices in hospitals not participating in the program, which tend to be smaller, more often rural, and less well-resourced. Prior studies have suggested that these hospitals might provide lower-quality care and have worse outcomes. As such, expansion of this program is key to understanding a broader swath of the American healthcare system as it relates to medical therapy for HFrEF and other chronic diseases. The AHA recently announced specific efforts aimed at enrolling rural hospitals in GWTG for stroke and coronary artery disease and future efforts will focus on rural heart failure programs. As the program expands to a broader range of rural hospitals, it has the potential to improve prescribing trends in historically underresourced settings and could address worse rural health outcomes driven by differences in terms of access to care, social determinants of health and quality of care delivery.

In conclusion, this study demonstrates a clear increase in GDMT prescription rates during HF hospitalization across the study population and identifies key areas for future studies. Initiation of optimal medical therapy represents a crucial intervention point in terms of reducing rehospitalization, morbidity and mortality. Opportunities to optimize care for HF patients remain for rural patients, women, and those with comorbidities. Future studies will therefore need to focus on optimizing clinician behavior during admission and post-discharge as well as improving systems of care more broadly to address these gaps in care.

Figure 1: Headshot:

Headshot of corresponding author