SPC365

Validation of a novel framework defining the acceptable standard of care for heart failure with reduced ejection fraction

Session: Posters - D. Heart Failure
Speaker: Pedro M. Lopes

Congress: CPC 2021
Topic: D. Heart Failure
Theme: 10. Chronic Heart Failure
Subtheme: 10.4 Chronic Heart Failure – Treatment
Session Type: Posters
FP Number: ---
Authors: Pedro M. Lopes; Francisco Albuquerque; Pedro Freitas; João Presume; Bruno m. Rocha; Gonçalo j. Cunha; Christopher Strong; António Tralhão; Marisa Trabulo; Jorge Ferreira; António Ventosa; Carlos Aguiar; Miguel Mendes; António m. Ferreira

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Background:</strong> </span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">In heart failure with reduced ejection fraction (HFrEF), uptitration of neurohormonal antagonists to trial-proven doses shown to reduce mortality is challenging and seldomly achieved in clinical practice. A major reason for underdosing of these agents is the lack of a clear description of what constitutes an acceptable standard of care in HFrEF. To address this limitation, a novel framework for describing the physician adherence to evidence-based treatment was recently proposed. The aim of our study was to evaluate and validate the proposed framework in a real-world population of patients with HFrEF.</span></span></p>

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<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Methods: </strong></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:black">A cohort of patients </span>with HFrEF, defined as left ventricular ejection fraction (LVEF) &lt;40%, <span style="color:black">under treatment with </span>neurohormonal antagonists for <span style="color:black">at least 3 months were retrospectively identified at a tertiary hospital&rsquo;s Heart Failure Clinic. </span>Demographic, clinical, echocardiographic and treatment data were assessed. Patients were divided in three strata for each neurohormonal antagonist, according to the proposed framework: <em>Status I</em> - patients receiving target doses or the highest tolerated dose; <em>Status II</em> - use of subtarget doses for reasons unrelated to clinically important intolerance; and <em>Status III - </em>not receiving the drug at any dose. The prognostic value of each strata was assessed for all-cause mortality.</span></span></p>

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<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong><span style="color:black">Results:</span></strong> </span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:black">A total of 408 patients (mean age 68 </span><span style="font-family:Symbol"><span style="color:black">&plusmn;</span></span><span style="color:black"> 12 years, 78% male, 63% ischemic etiology) were included.&nbsp; The median LVEF was 31% (IQR 25-36) and most patients were in NYHA class II or III [210 (51.5%) and 163 (40%), respectively]. Medical therapy is described in Table 1. </span><span style="color:black">During a median follow-up of 3.3 years (IQR 1.4-5.6), 210 patients died. On univariable analysis, achieving <em>Status I </em>of beta-blocker (BB) therapy (HR: 0.50; 95% CI: 0.32-0.81; <em>P</em>=0.004) or ACEi/ARB (HR: 0.56; 95% CI: 0.36-0.86; <em>P</em>=0.012) was associated with reduced all-cause mortality. The mortality of patients in <em>Status II</em> of BB </span>or<span style="color:black"> ACEi/ARB was similar to the mortality of those </span>not <span style="color:black">receiving the drug (HR for BB: 0.90; 95% CI: 0.53-1.52; <em>P</em>=0.69 and HR for ACEi/ARB: 0.71; 95% CI: 0.42-1.18; <em>P</em>=0.182) &ndash; figure 1. Achieving <em>Status I</em> of BB remained independently associated with reduced mortality after adjustment for several clinical and echocardiographic confounders (n=13) (adjusted HR: 0.59; 95% CI: 0.35-0.98; <em>P</em>=0.041).</span></span></span></p>

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<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong><span style="color:black">Conclusions: </span></strong></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">In this real-world population of patients with HFrEF, the vast majority of patients were in <em>Status I</em> of BB and ACEi/ARB therapy. Achieving <em>Status I</em> of BB therapy seems to be associated with reduced mortality, even after adjustment for several markers of disease severity, highlighting the need for uptitration of medical therapy to maximal tolerated doses according to trial-proven regimens.</span></span></p>