HFSA ePoster Library

Introduction: Guideline directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) is underutilized. Awareness of this clinical implementation gap has grown in recent years. We sought to characterize the proportions of GDMT and SGLT2i prescription among patients with incident HFrEF in a large integrated health system and to evaluate whether these prescription rates increased over time.
Methods: Using the Penn Medicine electronic health record (EHR) reporting database (Clarity, Epic Systems Inc., Verona, WI), we identified all patients who had an ICD-10-CM HF diagnosis as defined by a standard EHR grouper of HF diagnosis codes, listed in their active EHR problem list, medical history, or a prior encounter diagnosis at least twice. From this cohort, we then identified 1,428 unique individuals with incident HFrEF (LVEF < 40% ascertained from structured reporting system) between January 1, 2019 and September 30, 2019. Baseline GDMT dose was defined as dose ordered 30 days prior to and 30 days after HFrEF diagnosis. Follow up GDMT dose was defined as maximum dose ordered 31 days to 1 year after HFrEF diagnosis. In total, 897 individuals had baseline and follow up GDMT data for analysis. Beta-blocker (BB), ACEi/ARB/ARNI, MRA, and SGLT2i prescriptions were converted to dose equivalents and the proportions of guideline recommended doses (0%, 1-49%, 50-99%, 100+%) were calculated. Demographics and prescription data were compared via two-sample proportion tests.
Results: In the overall incident HFrEF cohort, median age was 69 years (IQR 59, 78). Women comprised 35% (n=500), and Black patients comprised 29.8% (n=425). A majority of patients (54.8%) were insured by Medicare. Median LVEF was 30% (IQR 20, 35.95). At baseline, 29% were on no BB, 36% were on no ACEi/ARB/ARNI, 83% were on no MRA, 99% were on no SGLT2i. At follow up, significantly fewer patients were on no GDMT (BB: 23%, ACEi/ARB/ARNI: 28%, MRA: 80%) and no SGLT2i (97%) (p<0.05 for all). At follow up, 14%, 12%, 14%, 0.8% were on 100+% of BB, ACEi/ARB/ARNI, MRA, and SGLT2i GDMT doses, respectively.
Conclusions: In this real world, diverse cohort of patients with incident HFrEF at a large integrated health system, the proportions of patients with orders for recommended target doses of BB, ACEi/ARB/ARNI, MRA, and SGLT2i within 1 year after HFrEF diagnosis remains unacceptably low. Future analyses will explore prescription rates by patient-, clinician- and specialty-level factors. Increasing GDMT prescription rates is critical to improve HFrEF outcomes.