Discontinuation of Heart Failure Pharmacotherapy in Older Adults With Frailty

Background Guideline‐directed medical therapy (GDMT) improves outcomes in heart failure irrespective of frailty status. Nevertheless, the magnitude of frailty‐associated discontinuation of GDMT remains insufficiently studied. We aimed to quantify 12‐month discontinuation rates of GDMT across frailty strata. Methods This retrospective cohort study used a nationwide insurer‐based database. We identified patients aged ≥65 years who were hospitalized for heart failure between 2014 and 2022 and newly initiated on at least 1 GDMT at discharge, including angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers/angiotensin receptor‐neprilysin inhibitors, β‐blockers, mineralocorticoid receptor antagonists, or SGLT2is (sodium‐glucose cotransporter‐2 inhibitors). Discontinuation was defined as a gap of 60 days without a prescription following the expected completion of the dispensed supply. The cumulative incidence of GDMT discontinuation within 12 months was estimated according to Hospital Frailty Risk Score, with death treated as a competing risk. Results We analyzed 33 155 patients (mean age: 83.2 years, women: 53.0%). The initiating rates were as follows: angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers/angiotensin receptor‐neprilysin inhibitors 48.3% (N=16 025), β‐blockers 54.9% (N=18 197), mineralocorticoid receptor antagonists 44.1% (N=14 608), and SGLT2is 5.9% (N=1948). The Hospital Frailty Risk Score categories were as follows: low (33.2%), intermediate (47.1%), and severe (19.7%). Discontinuation rates increased with frailty severity: angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers/angiotensin receptor‐neprilysin inhibitors 27.5%, 39.0%, 45.5% (for low, moderate, and high Hospital Frailty Risk Score, respectively, P<0.001); β‐blockers 22.0%, 28.4%, 33.6%, respectively (P<0.001); and SGLT2is, 32.3%, 34.7%, 40.2%, respectively, (P=0.008), but not for mineralocorticoid receptor antagonists 42.2%, 42.5%, and 42.3%, respectively, (P=0.22). Conclusions In older adults with heart failure, approximately one‐third discontinued GDMT within 12 months, and discontinuation appeared disproportionately common among those with frailty.