HFSA ePoster Library

Introduction: Underprescribing of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) remains a problem. Whether polypharmacy contributes to underprescribing is unknown. Hypothesis: We hypothesized that patients with polypharmacy would have lower rates of GDMT initiation compared to those without polypharmacy.
Methods: We examined Medicare beneficiaries aged ≥65 years hospitalized for HFrEF between 2003-2017 from REGARDS (Reasons for Geographic and Racial Difference in Stroke). We compared % with contraindications to GDMT, % eligible for GDMT-initiation during hospitalization, and % initiation of eligible indicated GDMT prior to discharge among those with and without polypharmacy. Polypharmacy was defined as ≥10 standing medications at admission. We examined the neurohormonal antagonists among all patients with HFrEF, anticoagulation among those with atrial fibrillation, and antiplatelet agents and statins among those with coronary artery disease.
Results: There were 334 participants included in this study. The mean age was 78 years, 38% were women, and 33% were Black. Polypharmacy was present among 43% of patients. Coronary artery disease was present in 78% of patients and 40% of patients had atrial fibrillation. Patients with polypharmacy had a lower prevalence of contraindications to neurohormonal antagonists, and a higher prevalence of contraindications to anticoagulation, antiplatelet agents, and statins. Those with polypharmacy had lower % initiation of eligible indicated GDMT (without contraindications) prior to discharge (Table 1).
Conclusion: Among patients with HFrEF, initiation of eligible indicated GDMT prior to discharge occurs less frequently in patients with polypharmacy compared to those without polypharmacy even after accounting for contraindications. Unique strategies are needed to optimize GDMT among patients with HFrEF and polypharmacy.

Table 1: Rates of Initiation and Contraindication of GDMT in Patients With and Without Polypharmacy

	Polypharmacy (N=143)	No Polypharmacy (N=191)
Mean # of eligible medications for initiation	1.45	2.1
Mean # of eligible medications initiated	0.35	0.9
% of eligible medications initiated	26	40
Patients with heart failure with reduced ejection fraction (N=334):
Beta blocker: Contraindication present (%)	21	27
Beta blocker: % of eligible patients initiated on medication	47	64
ACEi/ARB/ARNI/HYD-ISD*: Contraindication present (%)	32	39
ACEi/ARB/ARNI/HYD-ISD*: % of eligible patients initiated on medication	33	57
Mineralocorticoid receptor antagonist: Contraindication present (%)	39	40
Mineralocorticoid receptor antagonist: % of eligible patients initiated on medication	13	15
Patients with coronary artery disease (N=259):
Anti platelet: Contraindication present (%)	12	7.7
Anti platelet: % of eligible patients initiated on medication	30	56
Statin: Contraindication present (%)	5.2	2.1
Statin: % of eligible patients initiated on medication	25	45
Patients with atrial fibrillation (N=135):
Anticoagulation: Contraindication present (%)	32	17
Anticoagulation: % of eligible patients initiated on medication	6.3	32
Legend:	*ACEi/ARB/ARNI/HYD-ISD: ACE inhibitor/Angiotensin Receptor Blocker/Angiotensin Receptor Neprilysin Inhibitor/Hydralazine-Isosorbide Dinitrate