The Association of Guideline-Directed Medical Therapy Scores and Patient Outcomes in Heart Failure Patients Across the Spectrum of LVEF.

BACKGROUND

Guideline-directed medical therapy (GDMT) improves outcomes in heart failure with reduced ejection fraction (HFrEF), but its impact in patients with mildly reduced (HFmrEF) or preserved ejection fraction (HFpEF) is less defined.

METHODS

We analyzed data from 25,333 adults with ambulatory encounters for heart failure (HF) from 02/2022 - 2/2024 across > 300 clinics in 2 states. Patients were categorized by left ventricular ejection fraction (LVEF) into HFrEF (≤40%), HFmrEF (41-49%), and HFpEF (≥50%), excluding those with improved EF. An electronic health record-embedded GDMT score (range 0-8) was used to quantify therapy with ACEi/ARB/ARNI, beta-blockers, MRAs, and SGLT2 inhibitors. Primary outcome was a composite of all-cause mortality and hospitalization.

RESULTS

The final cohort included 11,810 with HFpEF, 2,249 with HFmrEF, and 6,134 with HFrEF. GDMT utilization was highest in HFrEF and lowest in HFpEF. Higher baseline GDMT scores were associated with lower risk of the composite outcome across all EF groups, with the greatest reductions observed at scores ≥6. ACEi/ARB/ARNI and SGLT2i use were associated with lower risk in HFpEF; ACEi/ARB/ARNI, beta-blocker, and MRA use were associated with lower risk in HFmrEF; and all four classes were associated with lower risk in HFrEF. ARNI use was associated with better outcomes compared to ACEi/ARB across the EF spectrum.

CONCLUSION

Comprehensive GDMT was associated with better outcomes across the LVEF spectrum. These findings support the need for prospective evidence to guide medical management in non-HFrEF populations.