Discontinuation of Heart Failure Pharmacotherapy in Older Adults With Frailty

Guideline-directed medical therapy (GDMT) improves outcomes in heart failure irrespective of frailty status. Nevertheless, the magnitude of frailty-associated discontinuation of GDMT remains insufficiently studied. We aimed to quantify 12-month discontinuation rates of GDMT across frailty strata.

This retrospective cohort study used a nationwide insurer-based database. We identified patients aged ≥65 years who were hospitalized for heart failure between 2014 and 2022 and newly initiated on at least 1 GDMT at discharge, including angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers/angiotensin receptor-neprilysin inhibitors, β-blockers, mineralocorticoid receptor antagonists, or SGLT2is (sodium-glucose cotransporter-2 inhibitors). Discontinuation was defined as a gap of 60 days without a prescription following the expected completion of the dispensed supply. The cumulative incidence of GDMT discontinuation within 12 months was estimated according to Hospital Frailty Risk Score, with death treated as a competing risk.

We analyzed 33 155 patients (mean age: 83.2 years, women: 53.0%). The initiating rates were as follows: angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers/angiotensin receptor-neprilysin inhibitors 48.3% (N=16 025), β-blockers 54.9% (N=18 197), mineralocorticoid receptor antagonists 44.1% (N=14 608), and SGLT2is 5.9% (N=1948). The Hospital Frailty Risk Score categories were as follows: low (33.2%), intermediate (47.1%), and severe (19.7%). Discontinuation rates increased with frailty severity: angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers/angiotensin receptor-neprilysin inhibitors 27.5%, 39.0%, 45.5% (for low, moderate, and high Hospital Frailty Risk Score, respectively, P<0.001); β-blockers 22.0%, 28.4%, 33.6%, respectively (P<0.001); and SGLT2is, 32.3%, 34.7%, 40.2%, respectively, (P=0.008), but not for mineralocorticoid receptor antagonists 42.2%, 42.5%, and 42.3%, respectively, (P=0.22).

In older adults with heart failure, approximately one-third discontinued GDMT within 12 months, and discontinuation appeared disproportionately common among those with frailty.