Optimization of Medical Treatment in Heart Failure with Reduced Ejection Fraction and Clinical Outcomes in the New Era

Abstract

Background: Patients with heart failure are at risk of rehospitalization and high mortality. Current heart failure guidelines recommend the evidence-based pharmacological management for heart failure with reduced ejection fraction (HFrEF) to improve clinical outcomes. The challenge is how to construct optimal treatment for better results and minimized adverse events in clinical practice.Objective: We aimed to determine the association between patients with HFrEF who were prescribed target or optimal dose of medications and clinical outcomes.Methods: This was an analytic study in patients with HFrEF from January 2008 to December 2019. Primary outcome was the composite of cardiovascular death or heart failure hospitalization. The secondary outcome was all-cause death. Univariate and multivariate analysis were used to estimate the independent effects of predictor variables and survival.Results: There were 345 patients were enrolled with mean age 58.34 ± 12.97 years. The majority of patients were male, NYHA functional class I-II and non-ischemic cardiomyopathy. Few patients were achieved target dose of ACEI/ARB (16.81%), beta-blockers (47.09%), spironolactone (6.34%) and ARNI (13.95%). At follow up, patients who received < 50% target dose of beta-blockers and ACEI/ARB were associated with more primary outcome (log rank p < 0.01), whereas those who received spironolactone cannot demonstrate the difference in outcome (log rank p = 0.09). In multivariate analysis, NYHA functional class III-IV (p = 0.003) and atrial fibrillation (p = 0.007) were an independent predictor of worse clinical outcomes. While, patients with improve LVEF (p < 0.001) and received ≥ 50% target dose of ACEI/ARB (p = 0.017) were an independent predictor of favorable outcomes.Conclusion: This study demonstrated significant gaps between clinical practice and guideline-directed medical therapy in current era of HFrEF therapies. Patients who received neurohormonal blockade medications ≥ 50% dosage of target dose were associated with improve LVEF and better outcomes.