Real-world challenges for guideline-directed medical therapy intolerance in heart failure: A single-center prospective cohort study

Abstract

Backgrounds: The use of guideline-directed medical therapy (GDMT) in heart failure (HF) has been shown to decrease hospitalization and mortality risks. However, the implementation of GDMT remains suboptimal. This study aimed to evaluate the challenges of GDMT intolerance in a real-world setting.

Methods: The study initially screened 263 patients diagnosed with acute HF. All patients attempted to initiate quadruple GDMT before discharge; patients who failed to initiate quadruple GDMT were classified in the GDMT Intolerant Group, while those who successfully initiated GDMT were classified in the GDMT Group. The primary endpoint was the time to first worsening HF events or death due to HF within 180 days.

Results: Nearly half of the study patients cannot tolerate quadruple therapy at discharge and the main intolerance reasons of GDMT were renal insufficiency and hypotension. Patients who tolerated quadruple GDMT at discharge were more likely to use quadruple at the endpoint GDMT (92.4 % vs 27.8 %). Only 13.4 % of overall patients ultimately used the maximum dose of all four GDMTs at endpoint, patients with de novo HF had better prognosis than ADCHF (Acute Decompensated Chronic HF) patients, and GDMT Initiation at discharge was associated with a reduced risk of worsening HF in both HF patients, and the more types of medication initiated at discharge, the better the prognosis of the patients.

Conclusions: Real-world implementation of GDMT and dose up-titration remains challenging, with a high proportion of patients unable to tolerate quadruple GDMT, with renal insufficiency and hypotension being the most challenging factors.

Keywords: Acute heart failure; Guideline directed medical therapy; Heart failure; Treatment intolerance.