Berry Natalia C, Sheu Yi-Shin, Chesbrough Karen, Bishop R Clayton, Vupputuri Suma
Department of Cardiology, Mid-Atlantic Permanente Medical Group, McLean, Virginia, USA.
Mid-Atlantic Permanente Research Institute, Mid-Atlantic Permanente Medical Group, Washington, DC, USA.
ESC Heart Fail. 2025 Jun;12(3):1861-1871. doi: 10.1002/ehf2.15193. Epub 2025 Jan 19.
Guideline-directed medical therapy (GDMT) is recommended for all patients with heart failure with reduced ejection fraction (HFrEF). Despite this, little data exist describing GDMT use in diverse, real-world populations including the use of vasodilators, prescribed primarily to Black populations. We sought, among a diverse population of HFrEF patients, to determine (1) GDMT use rates and target dosing by medication class and (2) predictors of GDMT use and target dosing by medication class.
We utilized electronic health records (EHRs) from Kaiser Permanente (KP) Mid-Atlantic States, a large integrated health system. Included patients had heart failure and left ventricular ejection fraction (EF) of ≤40% between 2015 and 2021. GDMT was defined by five medication classes-angiotensin-converting enzyme (ACE) inhibitors (ACEis)/angiotensin receptor blockers (ARBs)/angiotensin receptor-neprilysin inhibitors (ARNis), beta-blockers (BBs), mineralocorticoid receptor antagonists (MRAs), sodium-glucose cotransporter 2 inhibitors (SGLT2is) and vasodilators (Black patients only). Proportions of patients on GDMT and target dose rates were examined. Logistic regression determined, within each class, predictors of medication use and being at ≥80% of the target dose.
A total of 3154 patients were included. Among the 93.8% on some form of GDMT, 82.8%, 81.4%, 23.5%, 3.6% and 13.4% were on ACEis/ARBs/ARNis, BBs, MRAs, SGLT2is and vasodilators (Black patients only), respectively. Among treated patients, 45.8%, 21.4%, 77.6%, 100% and 14.7% were treated at ≥80% of the target dose for ACEis/ARBs/ARNis, BBs, MRAs, SGLT2is and vasodilators, respectively. Overall, increasing age, higher EF, atrial fibrillation/flutter, chronic obstructive pulmonary disease (COPD), prior stroke and dementia were associated with decreased odds of GDMT use. Conversely, higher body mass index (BMI), Black race, higher glomerular filtration rate (GFR), recent echo and cardiac defibrillator were associated with increased odds of GDMT use. Among treated, higher BMI, higher systolic blood pressure, haemoglobin A1C ≥ 6.5% and cardiac defibrillator were associated with higher odds of being at ≥80% of the target dose.
Our study using real-world data from a diverse health system demonstrated gaps in GDMT use among patients with HFrEF, specifically older patients with more comorbidities.
对于所有射血分数降低的心力衰竭（HFrEF）患者，推荐采用指南导向的药物治疗（GDMT）。尽管如此，关于GDMT在不同的现实世界人群中的使用情况，包括主要开给黑人人群的血管扩张剂的使用情况，数据却很少。我们试图在不同的HFrEF患者群体中确定：（1）按药物类别划分的GDMT使用率和目标剂量；（2）按药物类别划分的GDMT使用和目标剂量的预测因素。
我们利用了来自大型综合医疗系统凯撒永久医疗集团（KP）大西洋中部各州的电子健康记录（EHR）。纳入的患者在2015年至2021年期间患有心力衰竭且左心室射血分数（EF）≤40%。GDMT由五类药物定义——血管紧张素转换酶（ACE）抑制剂（ACEi）/血管紧张素受体阻滞剂（ARB）/血管紧张素受体脑啡肽酶抑制剂（ARNi）、β受体阻滞剂（BB）、盐皮质激素受体拮抗剂（MRA）、钠-葡萄糖协同转运蛋白2抑制剂（SGLT2i）以及血管扩张剂（仅针对黑人患者）。检查了接受GDMT治疗的患者比例和目标剂量率。逻辑回归确定了每类药物使用的预测因素以及达到目标剂量≥80%的预测因素。
共纳入3154例患者。在接受某种形式GDMT治疗的93.8%的患者中，分别有82.8%、81.4%、23.5%、3.6%和13.4%的患者使用ACEi/ARB/ARNi、BB、MRA、SGLT2i以及血管扩张剂（仅针对黑人患者）。在接受治疗的患者中，分别有45.8%、21.4%、77.6%、100%和14.7%的患者接受的治疗剂量达到ACEi/ARB/ARNi、BB、MRA、SGLT2i和血管扩张剂目标剂量的≥80%。总体而言，年龄增加、EF升高、心房颤动/扑动、慢性阻塞性肺疾病（COPD）、既往中风和痴呆与GDMT使用几率降低相关。相反，较高的体重指数（BMI）、黑人种族、较高的肾小球滤过率（GFR）、近期的超声心动图检查和心脏除颤器与GDMT使用几率增加相关。在接受治疗的患者中，较高的BMI、较高的收缩压、糖化血红蛋白A1C≥6.5%和心脏除颤器与达到目标剂量≥80%的几率较高相关。
我们使用来自不同医疗系统的真实世界数据进行的研究表明，HFrEF患者在GDMT使用方面存在差距，特别是合并症较多的老年患者。
