GDMT Rates Low in HFrEF, Particularly in Women

At 1 year after a diagnosis of heart failure with reduced ejection fraction (HFrEF), fewer than 10% of patients are on optimal guideline-directed medical therapy (GDMT), with women less likely than men to receive the drugs, an administrative claims study shows.

Throughout follow-up, women had lower use across every GDMT class compared with men. Sex differences were more evident in those with private insurance than in those with Medicare, and in younger versus older patients.  

To TCTMD, senior author Ambarish Pandey, MD (University of Texas Southwestern Medical Center, Dallas), said he was surprised and disappointed by how low the rates of GDMT were even in a contemporary database that tracked patients diagnosed between 2016 and 2020.

“By looking at a cohort like this up to 1 year from diagnosis of heart failure, it gives us a much deeper understanding of the disparities that are occurring not just at one timepoint, but across a fairly long care period,” he said.

HF guidelines from the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America recommend initiating quadruple therapy with sodium glucose cotransporter-2 (SGLT2) inhibitors, angiotensin receptor-neprilysin inhibitors (ARNIs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs) in tandem as swiftly as possible after a HFrEF diagnosis. The current study occurred prior to the addition of SGLT2s to the US and European HF guidelines.

Pronounced Sex and Age Disparities

Published online January 23, 2024, ahead of print, in Circulation, the study followed 63,759 patients (mean age 71.3 years; 44% female; 15% Black) with incident HFrEF. The deidentified patient information came from the Optum Clinformatics Data Mart Database, which is derived from administrative health claims among members of large commercial and Medicare Advantage insurance plans.

Between baseline and 3 months, the use of the three classes of GDMT increased. By 12 months, the rate of ACE inhibitors/ARBs/ARNIs was 65.2%, beta-blockers 64.3%, and MRAs 24.7%.

However, the proportion of the entire cohort who were receiving optimal GDMT increased from 3% at 3 months to just 6.2% at 12 months, while target GDMT—which is the class-specific target dose—was seen in only 1.4% of the cohort.

At 12 months, the proportion of women on optimal GDMT was 5.0%, as compared with 7.0% for men. In multivariable analysis, female sex was associated with a lower likelihood of achieving optimal GDMT (HR 0.77; 95% CI 0.71-0.83).

While there were no statistically significant interactions between sex and location or hospitalization during follow-up, interactions were seen between sex and insurance class (P for interaction = 0.005) and between sex and age (P for interaction = 0.009).

Compared with Medicare patients, those with commercial insurance were younger, had fewer comorbidities, and had greater baseline use of ACE inhibitors/ARBs/ARNIs, beta-blockers, and MRAs. At 12 months, the rate of optimal GDMT was 11.5% for commercially insured patients versus 4.9% for those with Medicare.

In patients 65 years and older, the rate of optimal GDMT at 12 months was 4.8% versus 10.9% in those under age 65. When younger female patients were compared with younger male patients, they had lower rates of use of optimal GDMT at every time point from 3 months through 12 months.

We know that GDMT rates are low in this population, but I think some people don’t realize how low they actually are. Ambarish Pandey

“We know that GDMT rates are low in this population, but I think some people don’t realize how low they actually are,” Pandey noted. “We have to actively seek all opportunities to improve GDMT utilization, and that includes [during] hospitalization, and it includes hopefully optimization even when patients are at home.”

The STRONG-HF trial showed that implementing rapid uptitration and initiation of all recommended GDMT with close follow-up during a HF hospitalization lowers rates of all-cause death and HF readmission.

Pandey said remote monitoring and careful follow-up from home of vital signs can keep patients out of the hospital while their medical therapy is still being optimized. “The patient doesn’t have to see the doctor to uptitrate the medicines every time,” he added. “That is the push that needs to come to get us where we need to be with regards to utilization of GDMT.”

Some have suggested a “hospital at home” strategy would be beneficial for many HF patients, although implementation remains a challenge.

“Another initiative by the American Heart Association is IMPLEMENT-HF, where they are using an app-based approach to self-management at home,” Pandey added. “Studies like that can hopefully provide us with more [insight into] tools that are useful for improving the utilization of GDMT in this patient population.”