Clinical outcomes for patients with severe HFrEF diagnosed and treated in a community setting with the 'four pillars' of pharmacotherapy

Since 2022 European and American guidelines (1,2) have recommended the 'four pillars' of pharmacotherapy for patients with reduced left ventricular systolic function (HFrEF). We have studied a large cohort of potential such patients referred to, and diagnosed in, a community setting to ascertain outcomes in those with the severest LV systolic dysfunction when appropriately treated.

We have previously shown that it is possible to achieve high levels of appropriate prescribing for patients with HFrEF (3). We have followed the subset of patients identified with an EF<35% who had achieved their maximum ceiling of tolerated medications and had repeated echocardiography at least three months later to determine clinical outcomes in this high risk group.

Patients referred with potential heart failure (signs, symptoms and raised BNP), and subsequently identified as having left ventricular systolic dysfunction by echocardiography using BSE criteria (4), were initiated on ACE/ARB/ARNIs, β-blockers, MRAs and SGLT-2is and these were uptitrated to maximum tolerated doses. They attended regular outpatient appointments with a consultant cardiologist and a specialist heart failure nurse and were also encouraged to self report any deterioration in heart failure symptoms. Echocardiography was repeated at least three months after achieving maximally tolerated therapy.

Outcome measures were: a) mortality, b) change in LV systolic function and c) any admission to hospital because of heart failure decompensation

Of 925 consecutive patients referred to our service over a 21 month period with suspected heart failure and a BNP >400 ng/l, 297 were identified as having HFrEF. Of these 96 were shown to have an EF<35% and fulfilled the criteria of achieving maximum tolerated pharmacotherapy and subsequent repeat echocardiography after at least three months.

Table 1 shows the number of these patients successfully maintained on each class of medication, their gender, age, and heart rhythm and the subsets for those surviving and dying.

Table 2 shows the subsequent LV systolic function of those surviving and on long term medical therapy.

Of the 84 patients still alive only 5 had been admitted with an episode of decompensated heart failure. It can be seen that 56 (58%) patients showed improved LV systolic function. Using BSE criteria 26 (27%) improved by one class, 14 (15%) by two classes and 16 (17%) showed complete normalisation of LV function. 12 patients died (12%), most early in the course of their treatment, and 28 (29%) showed no significant improvement in LV systolic function.

Not only was it possible to achieve high levels of appropriate prescribing for patients with HFrEF but also within this population a sizeable number of patients with initially very poor LV systolic function showed significant improvement in their EF and low numbers required subsequent hospital admission for worsening heart failure.