Incidence and determinants of sub-optimal drug treatment in chronic heart failure: a single center pilot survey

Abstract Background The latest European Society of Cardiology guidelines on heart failure (HF) recommend a pharmacological treatment including 4 drugs (ARNI or ACE–inhibitor, beta–blocker, SGLT–2 inhibitor and MRA), with a class I indication in patients with HFrEF. However, the implementation of the 4 pillars approach is still largely insufficient in clinical practice. The aim of the present study was to investigate incidence and determinants of sub–optimal HF drug–treatment. Methods We conducted a 2–months survey in the heart failure outpatient clinic at our first–level community hospital. Physicians were asked to record the drug treatment patients were actually taking, and in the absence of one of the four pillars drug, to specify the underlying reason. Results 100 patients were enrolled, mean age 72±10 years old, 32 females. There were 36 HFpEF and 64 HFrEF patients. Quadruple therapy was present in 67 (HFpEF 58%, HFrEF 72%). Prescription rates of the four pillars drugs were: ARNI/ACE–inhibitor 96% (HFpEF 92%, HFrEF 98%; p=0.097), beta–blockers 98% (HFpEF 97%, HFrEF 98%; p>0.99), SGLT–2 inhibitor 81% (HFpEF 72%, HFrEF 86%; p=0.093), MRA 82% (HFpEF 78%, HFrEF 84%; p=0.410). No significant associations between age and sex with pharmacological treatments were noted (all p>0.05). Considering left ventricular ejection fraction (LVEF) as a continuous variable, patients under ARNI and SGLT–2 inhibitor treatments had lower values (43±10% vs 36±9%, p=0.001 and 43±9% vs 38±10%, p=0.034 respectively). Main reasons absent treatment were presence of chronic kidney disease with or without hyperkalemia (ARNI: 7%; ACE–inhibitor: 1%; BB: 0%; SGLT–2 inhibitor: 3%; MRA: 8%) and LVEF value (ARNI: 7%; Ace–inhibitor: 0%; BB: 0%; SGLT–2 inhibitor: 3%; MRA: 2%). Beta–blocker was not prescribed in 2% of the patients due to bradycardia. Hypotension leading to treatment discontinuation was more common in the ARNI group (ARNI: 8%; ACE–inhibitor: 1%; others: 0%). Conclusions In our sample, more than two thirds of HF patients were prescribed the quadruple heart failure pharmacological treatment. Save for hypotension in the ARNI treated patients, a high drug tolerability was observed. Physician–guided lack of prescription was influenced by the presence of chronic kidney disease and absent drug reimbursement due to LVEF cut–off as per AIFA criteria at the time of prescription. Results of this survey highlights potential areas to improve adherence to guidelines–directed medical treatments.