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Guideline-directed medical therapy in real-world heart failure patients with low blood pressure and renal dysfunction
Xiaojing Chen1,2, Xiaotong Cui3,4, Erik Thunström3
1Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China. chenxiaojing_058@163.com.
Insights
Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) improves survival in patients with low blood pressure and renal dysfunction. Full GDMT, including ACEI/ARB, BB, and MRA, showed the best outcomes, emphasizing its importance in managing complex HFrEF cases.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Medicine
Background:
- Guideline-directed medical therapy (GDMT) including ACEI/ARB, BB, and MRA improves prognosis in heart failure with reduced ejection fraction (HFrEF).
- Low blood pressure (BP) and renal dysfunction pose challenges to implementing GDMT in HFrEF patients.
- This study investigates GDMT combinations' impact on mortality in HFrEF with these comorbidities.
Purpose of the Study:
- To assess the association between different combinations of GDMT and all-cause mortality in HFrEF patients with low BP and renal dysfunction.
- To evaluate the effectiveness of comprehensive GDMT versus less intensive regimens in a real-world setting.
- To identify optimal therapeutic strategies for HFrEF patients facing treatment limitations.
Main Methods:
- Retrospective analysis of 1464 HFrEF patients from the Swedish Heart Failure Registry with low BP (≤100 mmHg) and renal dysfunction (eGFR ≤60 ml/min/1.73m²).
- Patients were categorized into four groups based on GDMT combinations: full GDMT (ACEI/ARB+BB+MRA), ACEI/ARB+BB, ACEI/ARB+MRA, and ACEI/ARB only.
- All-cause mortality was the primary outcome, analyzed using adjusted hazard ratios after controlling for relevant clinical factors.
Main Results:
- Full GDMT (Group 1) was associated with the lowest all-cause mortality compared to other groups after adjustment.
- Hazard ratios for all-cause mortality were 1.04 (p=0.62) for ACEI/ARB+BB, 1.40 (p=0.009) for ACEI/ARB+MRA, and 1.71 (p<0.001) for ACEI/ARB only, relative to full GDMT.
- Patients receiving full GDMT were younger, had higher hemoglobin, and a greater proportion with EF <30%.
Conclusions:
- In HFrEF patients with low BP and renal dysfunction, comprehensive GDMT is linked to better survival.
- The survival benefit of full GDMT was most pronounced early after the index date and diminished over time.
- These findings support the use of full GDMT in complex HFrEF populations despite clinical challenges.
Background:
Among patients with heart failure and reduced ejection fraction (HFrEF), angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB), β-blockers (BB) and mineralocorticoid receptor antagonist (MRA) are known as guideline-directed medical therapy to improve prognosis. However, low blood pressure (BP) and renal dysfunction are often challenges prevent clinical implementation, so we investigated the association of different combinations of GDMT treatments with all-cause mortality in HFrEF population with low BP and renal dysfunction.
Methods:
This study initially included 51, 060 HF patients from the Swedish Heart Failure Registry, and finally 1464 HFrEF patients with low BP (systolic BP ≦ 100 mmHg) and renal dysfunction (estimated glomerular filtration rate (eGFR) ≦ 60 ml/min/1.73m2) were ultimately enrolled. Patients were receiving oral medication for HF at study enrollment, and divided into four groups (group 1-4: ACEI/ARB + BB + MRA, ACEI/ARB + BB, ACEI/ARB + MRA or ACEI/ARB only, and other). The outcome is time to all-cause mortality.
Results:
Among the study patients, 485 (33.1%), 672 (45.9%), 109 (7.4%) and 198 (13.5%) patients were in group 1-4. Patients in group 1 were younger, had highest hemoglobin, and most with EF < 30%. During a median of 1.33 years follow-up, 937 (64%) patients died. After adjustment for age, gender, LVEF, eGFR, hemoglobin when compared with the group 1, the hazard ratio for all-cause mortality in group 2 was 1.04 (0.89-1.21) (p = 0.62), group 3 1.40 (1.09-1.79) (p = 0.009), and group 4 1.71 (1.39-2.09) (p < 0.001).
Conclusions:
In real-world HFrEF patients with low BP and renal dysfunction, full medication of guideline-directed medical therapy is associated with improved survival. The benefit was larger close to the index date and decreased with follow-up time.
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