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Significant underutilization of angiotensin receptor neprolysin inhibitor (ARNI) and other evidence-based heart failure (HF) therapies in an outpatient clinic setting

Session Poster Session 3

Speaker Narendra Singh

Event : Heart Failure 2019

  • Topic : heart failure
  • Sub-topic : Chronic Heart Failure: Pharmacotherapy
  • Session type : Poster Session

Authors : N Singh (Atlanta,US), S Premji (Atlanta,US), D Ramakrishnan (Atlanta,US)

Authors:
N Singh1 , S Premji1 , D Ramakrishnan2 , 1Medical College of Georgia at Augusta University , Cardiology - Atlanta - United States of America , 2Atlanta Heart Specialists, LLC - Atlanta - United States of America ,

On behalf: Atlanta Heart Specialists

Citation:

Background: Multiple guidelines since 2016 have endorsed as a Class 1 recommendation, the use of an ARNI in pts with heart failure (HF) and reduced ejection fraction (HFrEF).

Methods: Retrospective chart review of all pts being treated for HF in a single, multi-site suburban, outpatient cardiology practice for the calendar year 2016.

Results: Of the 1607 pts identified 560 (35%) had HFrEF, 218 (14%) had mid range EF (HFmEF) and 819 (51%) had preserved EF (HFpEF). In comparison to the HFpEF group, HFrEF pts had a lower EF (26.9% vs 58.9%) were significantly younger (64.4 yrs vs 68.2 yrs, p < 0.0001) and more likely to have ischemic cardiomyopathy (37% vs 19.2%, p < 0.00001). Table 1 looks at evidence based therapy use at the first and last visit of 2016. 

In the HFrEF pts, the greatest % change in drug therapy was ARNI use with an appropriate decrease in ACEI/ARB use. There was however substantial overall underutilization of spironolactone, ARNI and device therapy in the HFrEF group. EF improved significantly in the HFrEF group (26.9% vs 32.4%, p< 0.0001) while decreased in HFpEF group (58.4% vs 56.3%, p< 0.0005). In comparison to the HFpEF group, HFrEF pts were more often hospitalized for HF (17% vs 11.5%, p < 0.004) and had a higher 1 year mortality rate (11.1% vs 6.2%, p < 0.002).

Conclusions: Our findings suggest that there is significant underutilization of ARNI therapy in contemporary cardiology practice. There is also some inappropriate use of ARNI in HFpEF pts. Even more concerning is the underutilization of spironolactone and device therapy in HFrEF pts despite longstanding national guidelines and a high 1-yr HF hospitalization and mortality rate.

Therapy

HFrEF

HFpEF

% use

1st visit

Last visit

% change

P

1st visit

Last visit

% change

P

B-Blocker

81.7

87.2

5.5

< 0.0002

73.2

76.7

3.5

0.11

ACEI/ARB

66.0

60.3

-5.7

0.04

55.6

58.6

3.0

0.21

Spironolactone

22.1

26.3

4.2

0.09

12.7

14.3

2.7

0.34

ARNI

3.6

16.5

12.9

< 0.00001

0.6

1.3

0.7

0.13

ICD/CRT

37.3

51.1

13.8

< 0.00001

6.1

6.7

0.6

0.61

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