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Perceived risk profile and treatment optimization in heart failure: an analysis from BIOlogy Study to TAilored
Masatake Kobayashi1, Adriaan A Voors2, Wouter Ouwerkerk3,4
1Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France.
Insights
Optimizing heart failure medications like ACEi/ARB and beta-blockers is crucial. Clinicians often miss up-titration targets for unclear reasons, impacting patient care and treatment effectiveness in heart failure with reduced ejection fraction.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Medicine
Background:
- Optimizing medication doses for heart failure with reduced ejection fraction (HFrEF) is frequently underperformed.
- The BIOlogy Study to TAilored Treatment in chronic heart failure (BIOSTAT-CHF) identified many patients not reaching target medication doses without clear reasons.
- A perceived risk profile may influence treatment optimization in HFrEF.
Purpose of the Study:
- To compare clinical characteristics and adverse events in HFrEF patients based on treatment up-titration status.
- To investigate reasons for not reaching target doses of ACEi/ARB and beta-blockers.
- To analyze factors associated with successful medication titration in HFrEF.
Main Methods:
- Study included 2100 HFrEF patients (LVEF≤40%) undergoing a 3-month titration protocol.
- Patients were categorized into three groups: unclear reason for missed up-titration, symptoms/side effects, and target doses achieved.
- Multinomial logistic regression analyzed clinical characteristics and adverse events across groups.
Main Results:
- For ACEi/ARB, 51.3% were in the unclear reason group, 25.9% due to symptoms/side effects, and 22.7% achieved target doses.
- For beta-blockers, 67.5% were in the unclear reason group, 20.2% due to symptoms/side effects, and 12.3% achieved target doses.
- Patients with missed up-titration (unclear or symptom-related) had poorer renal function, lower blood pressure, lower ejection fraction, more congestion, and lower heart rate compared to those achieving target doses.
Conclusions:
- Patients with missed up-titration for unclear reasons were older and had more comorbidities.
- Achieving target medication doses in HFrEF did not result in excess adverse events.
- The long-term adverse event patterns in patients with missed up-titration remain undetermined from this observational study.
Background:
Achieving target doses of angiotensin-converting-enzyme inhibitor/angiotensin-receptor blockers (ACEi/ARB) and beta-blockers in heart failure with reduced ejection fraction (HFrEF) is often underperformed. In BIOlogy Study to TAilored Treatment in chronic heart failure (BIOSTAT-CHF) study, many patients were not up-titrated for which no clear reason was reported. Therefore, we hypothesized that perceived-risk profile might influence treatment optimization.
Methods:
We studied 2100 patients with HFrEF (LVEF≤40%) to compare the clinical characteristics and adverse events associated with treatment up-titration (after a 3-month titration protocol) between; a) patients not reaching target doses for unclear reason; b) patients not reaching target doses due to symptoms and/or side effects; c) patients reaching target doses.
Results:
For ACEi/ARB, (a), (b) and (c) was observed in 51.3%, 25.9% and 22.7% of patients, respectively. For beta-blockers, (a), (b) and (c) was observed in 67.5%, 20.2% and 12.3% of patients, respectively. By multinomial logistic regression analysis for ACEi/ARB, patients in group (a) and (b) had lower blood pressure and poorer renal function, and patients in group (a) were older and had lower ejection fraction. For beta-blockers, patients in group (a) and (b) had more severe congestion and lower heart rate. At 9 months, adverse events (i.e., hypotension, bradycardia, renal impairment, and hyperkalemia) occurred similarly among the three groups.
Conclusions:
Patients in whom clinicians did not give a reason why up-titration was missed were older and had more co-morbidities. Patients in whom up-titration was achieved did not have excess adverse events. However, from these observational findings, the pattern of subsequent adverse events among patients in whom up-titration was missed cannot be determined.
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