Therapy gaps for patients with heart failure and reduced kidney function: A prospective cohort study

Despite emerging evidence for new pharmacotherapies to improve outcomes in patients with heart failure (HF) and kidney dysfunction, data on contemporary HF therapy use in this population are lacking. This study evaluated contemporary longitudinal treatment patterns in patients with HF across the spectrum of kidney function and left ventricular ejection fraction (LVEF).

In a prospective, observational cohort of 1401 HF patients, we examined HF therapy use over 2 years and dose intensity stratified by ambulatory estimated glomerular filtration rate (eGFR ≥60, 30 to <60 and <30 mL/min/1.73 m²) and HF with reduced (HFrEF), mildly reduced (HFmrEF) and preserved (HFpEF) ejection fraction. Clinical outcomes, incidence of hyperkalaemia (serum potassium > 5.5 mmol/L) and clinician-reported reasons for underutilizing HF therapies were examined.

Median age was 68 (58 to 76) years; 29% were female; 54%, 37% and 9% had an eGFR of ≥60, 30 to <60 and <30, respectively. Among patients with eGFR ≥60, 95%, 94%, 75% and 15% were on a beta-blocker (BB), renin-angiotensin system inhibitor (RASi), mineralocorticoid receptor antagonist (MRA) and sodium glucose cotransporter-2 inhibitor, respectively. In patients with eGFR <30, corresponding baseline rates were 88%, 68%, 35% and 7%. Utilization rates were similar in patients with eGFR 30 to <60 compared with eGFR ≥60; however, fewer patients were on guideline-directed dose intensities with 44% versus 57% for RASi and 19% versus 26% for MRA. However, >90% of patients were on a BB, with similar utilization rates across HF and eGFR categories. Baseline ARNI use was 29%, 24% and 11% in eGFR ≥60, 30 to <60 and <30, respectively. Trends in HF therapy use persisted over 2 years. Among patients with eGFR <30, kidney dysfunction was the most frequently cited reason for underutilizing RASi. Patients with eGFR <60 experienced higher all-cause mortality, hospitalization and higher rates of hyperkalaemia.

Gaps in HF therapy use persist in patients with comorbid kidney dysfunction. Targeted strategies to implement new therapies and improve adherence to HF treatments are necessary to improve outcomes in a highly comorbid and at-risk population.