TOPLINE:

Only 21.2% of US veterans with newly diagnosed heart failure with reduced ejection fraction (HFrEF) received all four drug classes of guideline-directed medical therapy (GDMT) over a median follow-up duration of 2.9 years. Some groups were more likely to start full therapy, and many patients died before receiving all four medications.

METHODOLOGY:

• Researchers conducted a retrospective cohort study to assess how long it took to start quadruple GDMT after the first diagnosis of HFrEF in veterans and which factors influenced the time.
• They reviewed pharmacy records of 52,850 veterans with incident HFrEF treated in the US Veterans Health Administration between January 2020 and December 2023; mean age of patients was 71.8 years, and 97.4% were men.
• The primary outcome was the achievement of quadruple therapy, defined as the concurrent use of a beta-blocker, a renin-angiotensin system inhibitor, a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor.
• Researchers defined the time to quadruple therapy as the first day on which all four medication classes overlapped in the records of a patient, allowing a 14-day grace period for refills.
• They also recorded relevant parameters including patient demographics, laboratory measures, comorbidities, and other medications.

TAKEAWAY:

• Only 21.2% of patients started all four classes of drugs during a median follow-up duration of 2.9 years, and they did so at a median duration of 197 days.
• After adjustment, the likelihood of achieving quadruple therapy was higher by 22% among Black patients, 21% among Hispanic patients, and 11% among those from other racial or ethnic groups compared with that among White patients (P ≤ .01 for all).
• Patients who paid a small fee when they filled a medication were 8% less likely to achieve quadruple therapy than those who did not make such copayments (P < .001).
• Over the follow-up period, 30.8% of patients died; 91% of those deaths occurred before patients had achieved quadruple therapy. Among those who did reach quadruple therapy, 59% had a recovery of left ventricular ejection fraction.

IN PRACTICE:

“Addressing modifiable barriers, such as medication copays, could improve equitable access to life-saving therapies and enhance outcomes for patients with HFrEF,” the researchers wrote.

“The prevailing practice of incremental, slow, and steady GDMT treatment is misaligned with the high clinical risk these patients face. To approach HFrEF with the urgency it deserves, we must recognize the need for speed in treatment,” three experts wrote in an editorial accompanying the journal article.

SOURCE:

This study was led by Joshua A. Jacobs, PharmD, PhD, of University of Utah in Salt Lake City. It was published online on April 1 in JAMA Cardiology.

LIMITATIONS:

Researchers recorded use of GDMT by class only and lacked data on dosing or titration. The cohort was almost entirely men with limited racial diversity. Medication exposure may have been misclassified due to incomplete fill data and disruptions related to pandemic.

DISCLOSURES:

This study was funded in part by the National Institute on Aging. One author reported serving as an associate editor of JAMA Cardiology. Several authors reported receiving research grants; personal, advisory, consulting, and/or speaking fees; data safety monitoring board and editorial fees; and salary support and having trial investigator roles in multiple pharmaceutical, healthcare, and research organizations.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.