ACC 2019: Heart failure patients not having medication doses increased to recommended targets

March 16, 2019 — Despite guideline recommendations, most heart failure patients eligible for medical therapies never have these therapies titrated to the target dose.

In current U.S. practice, the majority of patients who have heart failure with reduced ejection fraction do not receive medical therapy at guideline-recommended target doses, and their medications are often not titrated to the target dose during follow-up, according to new findings from DCRI researchers.

The study was led by DCRI fellow Stephen Greene, MD, and was presented on Saturday at the 2019 American College of Cardiology Scientific Sessions. In conjunction with the presentation, the study was published simultaneously in the Journal of the American College of Cardiology.

Strong clinical evidence has shown that multiple heart failure medications can substantially improve patient survival and quality of life, and guidelines recommend that these medications are titrated to a target dose so that patients receive the maximal benefit. However, Greene said, the group’s findings show that many patients eligible for these important medications are not receiving them or receiving only low doses, and that most patients never have doses of medication increased to the target dose at any point in time.

The study examined 2,588 U.S. outpatients enrolled in the CHAnge the Management of Patients with Heart Failure (CHAMP-HF) registry between December 2015 and July 2017. All the patients included had heart failure with reduced ejection fraction, complete medication data, and no contraindications to medical therapy.

The study focused on the four main classes of medical therapies proven to improve patient outcomes: angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB), angiotensin receptor-neprilysin inhibitors (ARNI), beta-blockers, and mineralocorticoid receptor antagonists (MRA).  The study then compared the use of each these therapies over a 12-month follow-up period.

“Understanding that guidelines recommend that we constantly work toward increasing the dose of these medications to the target dose if at all possible so that we best improve patient outcomes, we wanted to determine to what degree this happens in current U.S. practice, and to better understand the overall patterns of medication changes,” Greene said.

The proportion of patients receiving a target dose of medication at baseline ranged from 1.7 percent for ARNI to 25.4 percent for MRA. After 12 months, the team found the following:

  • For all medical therapies, more than 80 percent of patients had stable dosing over 12 month follow-up, with the vast majority of patients consistently receiving doses below the recommended target;
  • 7 percent of patients had ACEI/ARB therapy started or dose increased, while 11 percent had therapy discontinued or dose decreased;
  • 10 percent of patients had ARNI therapy started or dose increased, while 3 percent had therapy discontinued or dose decreased;
  • 10 percent of patients had beta-blocker therapy started or dose increased, while 7 percent had therapy discontinued or dose decreased;
  • 6 percent of patients had MRA therapy started or dose increased, while 4 percent had therapy discontinued or dose decreased;
  • Several high-risk patient characteristics were associated with higher likelihood of having medications discontinued or doses decreased.

“Clinicians should recognize that there is a strong tendency to not up-titrate or initiate medical therapy as patients continue to receive outpatient follow-up visits. Many of these patients are eligible for these important medications and would benefit from having them started or from having the doses increased,” said Greene.

“Overall, this study identifies major gaps in the quality of heart failure care in the U.S.,” he said. “Given that heart failure remains a leading cause of death, hospitalization, and impaired quality of life, every effort must be made to use all the tools proven to improve patient outcomes. As we care for each patient over time, we need to constantly work on starting each patient on the beneficial medications for which they are eligible, and then titrating each medication to the target or maximally tolerated dose. Every time we see a heart failure patient in practice, we should see this as a possible opportunity to improve the quality of their medical therapy, and in turn, improve their outcomes.”

The DCRI’s Adam DeVore, MD; C. Larry Hill, PhD; Laine Thomas, PhD; and Adrian Hernandez, MD, also contributed to this study. The analysis and the CHAMP-HF registry were funded by Novartis Pharmaceuticals Corporation.