Contemporary Guideline-Directed Medical Therapy for Heart Failure in the United States: The EMPACE Study

Randomized trials and clinical guidelines support early initiation of guideline-directed medical therapy (GDMT) for heart failure (HF). The EMPACE (Treatment Patterns of Guideline-Directed Medical Therapies in Heart Failure Patients in the Real-World) study examined GDMT use in US clinical practice among patients hospitalized with heart failure (HHF).

This observational cohort study examined US patient data from Optum's deidentified Market Clarity database (June 2020-September 2023). GDMT use was assessed in the 12 months before and after HHF. Discontinuation was assessed over 12 months after initiation.

Among 17 210 patients (73% HF with reduced ejection fraction [EF], 4%, HF with mildly reduced EF, 23% HF with preserved EF), mean age was 69.2 years, and 60% were male. Before HHF, among patients with HF with reduced EF (HFrEF), only 1% received quadruple therapy; use of individual therapies was beta blockers 68%, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 64%, mineralocorticoid receptor antagonists 23%, angiotensin receptor-neprilysin inhibitors (ARNI) 14%, and sodium-glucose cotransporter-2 inhibitor (SGLT2i) 5%. After HHF, GDMT use improved modestly: quadruple therapy 2%, beta blockers 84%, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 72%, mineralocorticoid receptor antagonists 38%, ARNI 26%, and SGLT2i 13%. Among patients receiving therapy post discharge, mean time-to-initiation was longest for SGLT2i (88 days) and shortest for beta blockers (15 days). Mean time-to-quadruple therapy was 109 days. ARNI had the highest 12-month discontinuation rate (62%), followed by mineralocorticoid receptor antagonists (57%), SGLT2i (55%), and beta blockers (51%). Among patients with HF with mildly reduced EF (HFmrEF) and HF with preserved EF (HFpEF), only 7% each received SGLT2i before HHF compared with 12% and 9% post-HHF (each with mean time-to-initiation 28 days), respectively.

Among patients hospitalized for HFrEF in contemporary US clinical practice, there were significant gaps in prehospitalization quadruple therapy and only modest GDMT improvement post-discharge, with delayed initiation and high discontinuation rates. Similar patterns were observed with SGLT2i among patients with HFmrEF and HFpEF.