Initiation and titration of guideline-directed medical therapy during hospitalization for acute decompensation of heart failure with reduced ejection fraction.

BACKGROUND AND OBJECTIVES: Heart failure with reduced ejection fraction (HFrEF) is a leading cause of morbidity and mortality worldwide. Initiating or maintaining guideline-directed medical therapy (GDMT) during hospitalization is crucial, as early intervention can significantly influence the prognosis. GDMT includes renin-angiotensin-aldosterone system inhibitors (angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blocker (ARB), angiotensin receptor-neprilysin inhibitor (ARNI) and mineralocorticoid receptor antagonist (MRA)), beta-blockers and sodium-glucose cotransporter-2 inhibitors (SGLT2i). Our objective was to evaluate the percentage of patients achieving quadruple therapy during hospitalization, document reasons for non-achievement, and describe outcomes in special subgroups (chronic kidney disease (CKD) or advanced age).

METHODS: We conducted a prospective single-center study from September 2021 to February 2024, including patients hospitalized for acute decompensated HFrEF with ejection fraction ≤40% treated by the heart failure unit (HFU) of our hospital.

RESULTS: One hundred ninety-six patients were included, with a mean age of 69.2 years. Common comorbidities included hypertension (70.4%), diabetes (41.8%) and CKD (35.2%). The median hospital stay was 8 days. At discharge, ACEI/ARB/ARNI were prescribed in 92.9% of patients, beta-blockers in 88.8%, MRA in 68.9%, and SGLT2i in 91.8%. A remarkable 58.2% of patients received quadruple therapy.

CONCLUSIONS: Our study highlights the tolerability and safety of GDMT initiation and titration in hospitalized patients with HFrEF. A substantial proportion of patients were successfully managed with quadruple therapy at discharge, including those with chronic kidney disease (CKD) or advanced age. The main limiting factors were hypotension, renal function deterioration, and electrolyte imbalances.