The optimization of guideline-directed medical therapy during hospitalization among patients with heart failure with reduced ejection fraction in daily clinical practice.

INTRODUCTION
Hospitalization due to heart failure (HF) progression is associated with poor prognosis. This highlights the role of the implementation of guideline-directed medical therapy (GDMT) in improving the morbidity and mortality of patients with heart failure with reduced ejection fraction (HFrEF). There is limited data about the intrahospital applicability of GDMT in real-world circumstances. We aimed to assess retrospectively the use of cornerstone GDMT including RASi (ACEI/ARB/ARNI), βB, MRA, and SGLT2i treatment in a consecutive real-world HFrEF patient population admitted with signs and symptoms of heart failure to the HF unit of a Hungarian tertiary cardiac centre between 2019 and 2021. The independent predictors of therapy optimization and the applicability of new HFrEF medication (ARNI, SGLT2i, vericiguat) were also investigated.


METHODS
Statistical comparison of admission and discharge medication was accomplished with Fisher's exact test. The independent predictors of the introduction of triple therapy (RASi+βB+MRA) were analyzed using univariate and multivariate logistic regression. The proportion of patients eligible for vericiguat based on the inclusion and exclusion criteria of the VICTORIA trial was also investigated, as well as the number of patients suitable for ARNI and SGLT2i, taking into account the contraindications of application contained in the ESC 2021 HF Guidelines.


RESULTS
238 patients were included. During hospitalization, the use of RASi (69% vs. 89%) (ACEI/ARBs (58% vs. 70%), ARNI (10% vs. 19%)), βBs (69% vs. 85%), and MRAs (61% vs. 95%) increased significantly (p<0.05) compared to at admission, and the use of SGLT2i (3% vs. 11%) also rose (p=0.0005). The application ratio of triple (RASi+βB+MRA; 43% vs. 77%) and quadruple (RASi+βB+MRA+SGLT2i; 2% vs. 11%) therapy increased as well (p<0.0001). The independent predictors of discharge application of triple therapy revealed through multivariate logistic regression analysis were age, duration of hospitalization, eGFR, NTproBNP, and presence of diabetes mellitus. Sixty-eight percent of the cohort would have been suitable for vericiguat, 83% for ARNI, and 84% for SGLT2i.


CONCLUSION
High rates of application of disease-modifying drugs are achievable among hospitalized HFrEF patients in severe clinical condition, thus awareness of the need for the initiation of the former must be raised.