Contemporary Guideline-Directed Medical Therapy for Heart Failure in the United States: The EMPACE Study.

BACKGROUND: Randomized trials and clinical guidelines support early initiation of guideline-directed medical therapy (GDMT) for heart failure (HF). The EMPACE (Treatment Patterns of Guideline-Directed Medical Therapies in Heart Failure Patients in the Real-World) study examined GDMT use in US clinical practice among patients hospitalized with heart failure (HHF). METHODS: This observational cohort study examined US patient data from Optum's deidentified Market Clarity database (June 2020-September 2023). GDMT use was assessed in the 12 months before and after HHF. Discontinuation was assessed over 12 months after initiation. RESULTS: Among 17 210 patients (73% HF with reduced ejection fraction [EF], 4%, HF with mildly reduced EF, 23% HF with preserved EF), mean age was 69.2 years, and 60% were male. Before HHF, among patients with HF with reduced EF (HFrEF), only 1% received quadruple therapy; use of individual therapies was beta blockers 68%, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 64%, mineralocorticoid receptor antagonists 23%, angiotensin receptor-neprilysin inhibitors (ARNI) 14%, and sodium-glucose cotransporter-2 inhibitor (SGLT2i) 5%. After HHF, GDMT use improved modestly: quadruple therapy 2%, beta blockers 84%, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 72%, mineralocorticoid receptor antagonists 38%, ARNI 26%, and SGLT2i 13%. Among patients receiving therapy post discharge, mean time-to-initiation was longest for SGLT2i (88 days) and shortest for beta blockers (15 days). Mean time-to-quadruple therapy was 109 days. ARNI had the highest 12-month discontinuation rate (62%), followed by mineralocorticoid receptor antagonists (57%), SGLT2i (55%), and beta blockers (51%). Among patients with HF with mildly reduced EF (HFmrEF) and HF with preserved EF (HFpEF), only 7% each received SGLT2i before HHF compared with 12% and 9% post-HHF (each with mean time-to-initiation 28 days), respectively. CONCLUSIONS: Among patients hospitalized for HFrEF in contemporary US clinical practice, there were significant gaps in prehospitalization quadruple therapy and only modest GDMT improvement post-discharge, with delayed initiation and high discontinuation rates. Similar patterns were observed with SGLT2i among patients with HFmrEF and HFpEF.

Duke Scholars

Author Stephen Greene Medicine, Cardiology