In-hospital Utilization and Dose Optimization of Guideline-Directed Medical Therapies among Acute Heart Failure...

Despite robust evidence and strong recommendations supporting the incremental and dose-related benefit of combined neurohormonal blockers (guideline-directed medical therapy [GDMT]) in heart failure with reduced ejection fraction (HFrEF), real-world data shows significant gaps in uses and/or dosing of these therapies.

As heart failure (HF) hospitalization is viewed as an opportunity for the initiation and optimization of HF life-saving medications and the paucity of data exploring this important issue in Yemen, the current study aims to fill this gap.

The objective of this study was to evaluate the use, number, and dose optimization of the GDMT in a cohort of hospitalized patients with HFrEF in Yemen.

We included 1408 Yemeni patients with available ejection fraction (EF) enrolled in the Gulf CARE registry from February to November 2012. In this analysis, we included only four classes of GDMT, renin-angiotensin system inhibitors (RASi), evidence-based beta-blockers, and mineralocorticoid receptor antagonist (MRA). Each drug dose was converted to the equivalent daily dose of a selected representative drug. We explored the prescription of these drugs either separately or in combination and the target dose (TD) achievement for each drug at admission and discharge.

Among the1408 patients recruited, 916 patients (65%) were males and mean age was 53.5 ± 15.4 years, 53% (n = 748) presented with HFrEF (EF < 40%), 21% (n = 299) with HFpEF (EF ≥ 50%), and 26% (n = 361) with HFmrEF (Heart failure with mildly reduced ejection fraction) (EF 40-49%). Beta-blockers, renin-angiotensin system inhibitors, and MRA were prescribed to 28% (n = 400), 51% (n = 716), and 10% (n = 143) at baseline and 69.5% (n = 978), 82% (n = 1157), and 59% (n = 831) on discharge, respectively. The rate of TD achievement was (0.0% vs. 3.6% (n = 35]) for beta-blockers and (0.279% [n = 2] vs. 1.5% [n = 17]) for renin-angiotensin system inhibitors on baseline and discharge, respectively. Among 748 patients with HFrEF, 36% (n = 270) were not receiving any GDMT at baseline, while triple therapy was prescribed to 10% (n = 74) at baseline and 61.5% (n = 460) on discharge.

A substantial gap in GDMT implementations with both underutilization and low TD achievement in patients with HFrEF in Yemen.