Although ACEI/ARB/ARNI therapy showed high adherence, BBs and MRAs were less frequently used, and SGLT2Is were under-prescribed, greater efforts are needed to improve adherence to ESC recommendations at discharge.
Abstract
Introduction: Heart failure is a leading cause of hospitalization and mortality worldwide.
Adherence to the European Society of Cardiology (ESC) guidelines can significantly reduce
mortality and rehospitalization rates. However, many patients are discharged without optimal
guideline-directed therapy.
Aim: To evaluate the implementation of the 2021 ESC guidelines (with 2023 updates) for
heart failure management in clinical practice.
Material and methods: This prospective, observational study included 118 patients hospitalized for acute heart failure from December 1, 2024, to January 31, 2025. Prescription rates
at discharge for the four recommended drug classes were assessed: Angiotensin-converting
enzyme inhibitors (ACEIs), Angiotensin receptor blockers (ARBs), or Angiotensin receptor
neprilysin inhibitors (ARNIs), Beta-blockers (BBs), Mineralocorticoid receptor antagonists
(MRAs), Sodium-glucose cotransporter-2 inhibitors (SGLT2Is). Only patients without contraindications were considered eligible. Common clinical reasons for non-prescription were
also examined.
Results: The ACEI/ARB/ARNI therapy was prescribed to 92.7% of eligible patients, BBs to
79.1%, MRAs to 61.7%, and SGLT2Is to 46.7%. Only 38.1% of the total population received all four drug classes at discharge. Contraindications for ACEI/ARB/ARNI included renal
dysfunction, hyperkalemia, and hypotension. The MRAs were limited by renal insufficiency
and hyperkalemia. Beta-blockers were often withheld due to bradycardia, asthma, or hypotension. Also, SGLT2Is were avoided in patients with significantly impaired renal function or
hypotension.
Conclusion: Implementation of guideline-directed therapy in heart failure patients remains
suboptimal. Although ACEI/ARB/ARNI therapy showed high adherence, BBs and MRAs
were less frequently used, and SGLT2Is were under-prescribed. Greater efforts are needed to
improve adherence to ESC recommendations at discharge.
Guideline-directed medical therapy (GDMT) improves outcomes in heart failure with reduced ejection fraction (HFrEF). However, implementation remains suboptimal, and evidence for inpatient pharmacist-led interventions is limited. We evaluated the association between a pharmacist-led electronic medical record (EMR)-embedded checklist and GDMT use in hospitalized patients with acute heart failure.
A single-center, retrospective, non-randomized study with a historical control group was conducted. Adult patients hospitalized with acute heart failure from October 2021 to March 2023 were enrolled. Patients admitted between October 2022 and March 2023 formed the pharmacist-led GDMT checklist intervention group, whereas those admitted between October 2021 and March 2022 served as historical controls. Primary outcomes were discharge implementation and new initiation rates of individual GDMT agents (renin–angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists [MRA], sodium–glucose cotransporter-2 inhibitors [SGLT2i]) and quadruple therapy. Exploratory multivariable logistic regression was performed for quadruple therapy use at discharge in patients with HFrEF. Secondary outcomes included target-dose achievement, exploratory 90-day heart failure readmission, and all-cause mortality.
A total of 103 patients were included (49 controls, 54 intervention). Among patients with HFrEF (22 controls, 23 intervention), the intervention group had higher prescription rates of MRA (87.0% vs. 59.1%,
p
= 0.047) and SGLT2i (95.7% vs. 72.7%,
p
= 0.047). Quadruple therapy was achieved in 78.3% vs. 40.9% (
p
= 0.016). The proportion of patients who newly achieved quadruple therapy during hospitalization was also higher in the intervention group (83.3% vs. 35.0%,
p
= 0.038). In the exploratory multivariable model, the intervention remained associated with higher odds of quadruple therapy use at discharge. Target-dose achievement was similar between groups. In mildly reduced/preserved EF, discharge SGLT2i use tended to be higher in the intervention group (
p
= 0.062). Exploratory 90-day outcomes showed no clear between-group differences and were limited by incomplete follow-up and insufficient statistical power.
The pharmacist-led EMR-embedded checklist intervention was associated with higher discharge implementation and in-hospital initiation of HFrEF-directed GDMT, particularly MRA, SGLT2i, and quadruple therapy. This simple checklist-based approach may support evidence-based pharmacotherapy optimization and warrants confirmation in larger multicenter studies with long-term follow-up.
Hikaru Katagiri, Komei Tanaka, Ryuji Kobayashi et al.· Journal of Pharmaceutical He...· 0 citations
Incomplete implementation of quadruple GDMT in HFrEF remains a major modifiable opportunity to reduce preventable deaths and HF hospitalizations in the United States.
Mohammad Keykhaei, A. T. Sandhu, Priscilla Y. Hsue et al.· JACC. Heart failure· 1 citation
Heart failure (HF) remains a major cause of morbidity and mortality globally and continues to pose a significant public health challenge in Nigeria. This retrospective study reviewed 156 HF prescriptions from adult patients attending the cardiology clinic at DELSUTH between January 2020 and December 2024. Most patients were male (64.7%) and aged 50–64 years, with New York Heart Association (NYHA) Class II being the most common diagnosis (42.3%). Diuretics were the most frequently prescribed medications—spironolactone (82.7%) and furosemide (71.2%)—followed by Angiotensin Converting Enzyme (ACE) inhibitors (50.9%), beta-blockers (47.4%), and antithrombotic agents (48.7%). Use of newer guideline-recommended therapies such as Angiotensin Receptor Neprilysin Inhibitors (ARNIs) (8.3%) and Sodium Glucose Cotransporter 2 (SGLT2) inhibitors (8.7%) was low. Medication therapy problems occurred in 7.7% of prescriptions, mainly non-adherence (3.2%) and administration errors (1.9%). Most prescribers (41.7%) followed ACC/AHA guidelines, and all prescriptions involved multidrug therapy issued by cardiologists. The study shows strong adherence to standard HF management but highlights limited access to newer therapies and persistent issues with adherence and minor edication errors.
J. Arute, Muobosa Wilson Oteri, Chifumnaya Solomon Nweke et al.· Journal of Pharmacy & Bi...· 0 citations
OBJECTIVE
To investigate the impact of the 2021 guideline update on guideline-directed medical therapy (GDMT) utilization in patients with heart failure (HF).
BACKGROUND
The 2021 update of the Japanese guidelines for HF management followed the introduction of sacubitril/valsartan and dapagliflozin into clinical practice. However, the impact of this guideline update on drug utilization patterns remains unclear.
MATERIALS AND METHODS
Patient data were obtained from the Japanese employee health insurance claims database (JMDC). The simple GDMT score was determined based on the combination and dose of four key pharmacological classes: β-blockers, renin-angiotensin system inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors. Because a simple GDMT score of ≥ 5 has been associated with improved prognosis in patients with HF, patients with scores ≥ 5 were classified into the high-score group for analysis.
RESULTS
Following the guideline update, the proportion of patients in the high-score group increased from 6.97% (n = 4,013) to 9.33% (n = 6,363), standardized difference 0.09. The mean simple GDMT score also showed a small but statistically significant increase (5.72 ± 0.79 vs. 6.00 ± 1.09) with standardized difference 0.28. This upward trend was particularly marked for the prescription rates of sacubitril/valsartan and dapagliflozin (sacubitril/valsartan: 1.40% before the update vs. 22.57% after the update; standardized difference, 0.69; dapagliflozin: 12.41% before the update vs. 26.64% after the update; standardized difference, 0.36).
CONCLUSION
The 2021 guideline update was associated with increased use of sacubitril/valsartan and dapagliflozin, resulting in greater overall GDMT intensity. However, these findings are limited to data from 2021, and further long-term studies are needed to evaluate trends in GDMT utilization.
T. Uno, K. Hosomi, S. Yokoyama· International journal of cli...· 0 citations
BACKGROUND
Real-world data regarding diuretic strategies and associated outcomes in patients hospitalized for heart failure (HF) in community health systems are limited.
OBJECTIVES
Evaluate associations between initial diuretic therapy, markers of decongestion, and clinical outcomes in patients hospitalized for HF.
METHODS
Patients hospitalized for HF from 2015-2022 across 30 health systems in the U.S. were identified in the Truveta national database. High dose loop diuretics were defined as >2.5X home dose or >160 mg IV furosemide equivalent over 24 hours. Four study groups were defined based on most intensive diuretic strategy used within 48 hours of admission: 1) high dose loop diuretics with adjuvant therapy (thiazide or acetazolamide), 2) high dose loop diuretics alone, 3) low dose loop diuretics with adjuvant therapy, and 4) low-dose loop diuretics alone. Multivariable logistic and linear regression models adjusted for clinical and demographic covariates were developed to evaluate associations between initial diuretic strategies and both in-hospital outcomes (acute kidney injury [AKI]), hemoconcentration, and weight change) and the composite of readmission or death.
RESULTS
Patients were treated with low dose loop diuretics (N=81,734; 74.9%), high dose loop diuretics (N=17,187; 15.7%), low dose loop diuretics plus adjuvant therapy (N=7,027; 6.4%), and high dose loop diuretics plus adjuvant therapy (N=3,210; 2.9%). Patients treated with more intensive strategies had greater illness severity, including more frequent prior HF hospitalizations and worse kidney function. Adjusted weight loss during hospitalization was greater for patients treated with more intensive strategies (high dose loop with adjuvant: 4.6 lbs [4.0-5.2]; high dose loop alone: 2.1 lbs [1.9-2.4]; low dose loop with adjuvant: 1.4 lbs [1.0-1.8]), as were adjusted odds of AKI. The adjusted odds of 90-day readmission/death were not lower with more intensive initial diuretic strategies. However, odds of 90-day readmission/death were lower for every 5 lbs of achieved weight loss (adjusted odds ratio: 0.97, 95% confidence interval 0.96-0.97).
CONCLUSIONS
More intensive diuretic strategies were used in sicker patients, improved in-hospital decongestion, but were not associated with improved 90-day outcomes. However, greater weight loss was associated with modestly lower risk of death or readmission. These data highlight the need for prospective studies to evaluate if enhancing decongestion can improve outcomes in patients hospitalized for HF.
A. Varshney, A. Ambrosy, Adam Furst et al.· Journal of Cardiac Failure· 0 citations
INTRODUCTION AND OBJECTIVES
Guidelines recommend early initiation of the 4 pillars of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF), but real-world evidence on quadruple therapy (QT) at discharge remains limited in Latin America.
METHODS
We conducted a retrospective cohort study of consecutive patients with HFrEF discharged from a tertiary cardiovascular center in Colombia (2022-2026). Patients were classified as receiving QT, defined as all 4 GDMT pillars, or incomplete therapy (IT, 0-3 pillars). Propensity-score optimal full matching was performed using 26 covariates. The primary endpoint was 30-day death or readmission. The robustness of the mortality findings was assessed using the primary estimator and 4 sensitivity analyses.
RESULTS
Among 3839 patients (median age, 68.2 years; 71.2% male), 2758 (71.8%) were discharged on QT. The 30-day composite endpoint occurred in 751 patients (19.6%). QT was associated with a lower risk of death or readmission (RR, 0.71; 95%CI, 0.58-0.88; P = .001). Mortality showed a consistent direction of association (RR, 0.61; 95%CI, 0.37-1.01; P = .052), with the 95%CI excluding unity in all 4 sensitivity analyses. Readmission was lower with QT (cause-specific HR, 0.73; 95%CI, 0.56-0.95; P = .017). Findings in the Chagas subgroup (n = 614) were directionally consistent with those in the overall cohort, with no significant treatment-by-subgroup interaction.
CONCLUSIONS
In this Latin American HFrEF cohort, QT at discharge was associated with a lower risk of 30-day death or readmission. The magnitude of the mortality association may partly reflect residual confounding rather than a pharmacological effect. These findings support the feasibility of QT prescription in a tertiary care setting in a low- and middle-income country.
L. E. Echeverría, Lyda Z. Rojas, A. Serrano-García et al.· Revista Española de Cardiolo...· 0 citations
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