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Cited by 500Heart Failure Treatment and ManagementHeart rate and cardiovascular healthBlood Pressure and Hypertension Studies

The DOI matches its Crossref record; 25 of the 25 references it cites were found in a registry or an index.

Titration of Medical Therapy for Heart Failure With Reduced Ejection Fraction

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Greene, Stephen J., Fonarow, Gregg C., DeVore, Adam D., Sharma, Puza P., Vaduganathan, Muthiah, Albert, Nancy M., Duffy, Carol I., Hill, C. Larry, McCague, Kevin, Patterson, J. Herbert, Spertus, John A., Thomas, Laine, Williams, Fredonia B., Hernandez, Adrian F., Butler, Javed·2019·Journal of the American College of Cardiology
DOI 10.1016/j.jacc.2019.02.015PMC PMC7197490
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Abstract

Background Guidelines recommend that patients with heart failure with reduced ejection fraction (HFrEF) have medical therapy titrated to target doses derived from clinical trials, as tolerated. The degree to which titration occurs in contemporary U.S. practice is unknown.Objectives This study sought to characterize longitudinal titration of HFrEF medical therapy in clinical practice and to identify associated factors and reasons for medication changes.Methods Among 2,588 U.S. outpatients with chronic HFrEF in the CHAMP-HF (Change the Management of Patients with Heart Failure) registry with complete medication data and no contraindications to medical therapy, use and dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker, and mineralocorticoid receptor antagonist (MRA) were examined at baseline and at 12-month follow-up.Results At baseline, 658 (25%), 525 (20%), 287 (11%), and 45 (2%) patients were receiving target doses of MRA, beta-blocker, ACEI/ARB, and ARNI therapy, respectively. At 12 months, proportions of patients with medication initiation or dose increase were 6% for MRA, 10% for beta-blocker, 7% for ACEI/ARB, and 10% for ARNI; corresponding proportions with discontinuation or dose decrease were 4%, 7%, 11%, and 3%, respectively. Over 12 months, <1% of patients were simultaneously treated with target doses of ACEI/ARB/ARNI, beta-blocker, and MRA. In multivariate analysis, across the classes of medications, multiple patient characteristics were associated with a higher likelihood of initiation or dose increase (e.g., previous HF hospitalization, higher blood pressure, lower ejection fraction) and discontinuation or dose decrease (e.g., previous HF hospitalization, impaired quality of life, more severe functional class). Medical reasons were the most common reasons for discontinuations and dose decreases of each therapy, but the relative contributions from patient preference, health team, and systems-based reasons varied by medication.Conclusions In this contemporary U.S. registry, most eligible HFrEF patients did not receive target doses of medical therapy at any point during follow-up, and few patients had doses increased over time. Although most patients had no alterations in medical therapy, multiple clinical factors were independently associated with medication changes. Further quality improvement efforts are urgently needed to improve guideline-directed medication titration for HFrEF.

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Authors
Greene, S. J., Fonarow, G. C., DeVore, A. D., Sharma, P. P., Vaduganathan, M., Albert, N. M., Duffy, C. I., Hill, C. L., McCague, K., Patterson, J. H., Spertus, J. A., Thomas, L., Williams, F. B., Hernandez, A. F., & Butler, J.
Affiliations
  • Duke University (US)
  • University of California, Los Angeles (US)
  • Novartis (United States) (US)
  • Brigham and Women's Hospital (US)
  • Cleveland Clinic (US)
  • University of North Carolina at Chapel Hill (US)
  • University of Missouri–Kansas City (US)
  • University of Mississippi Medical Center (US)
Corresponding author
Butler, Javed
ORCID
Venue
Journal of the American College of Cardiology
Publisher
Elsevier BV
Published
2019-05
Volume
73
Issue
19
Pages
2365-2383
ISSN
0735-1097 (ISSN-L)
DOI
10.1016/j.jacc.2019.02.015
PMC
PMC7197490
OpenAlex
W2919920736
Cited by
500
References
25
Citations by year
2026: 45 · 2025: 51 · 2024: 71 · 2023: 93 · 2022: 72 · 2021: 74 · 2020: 66 · 2019: 26
FWCI
42.85
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of the American College of Cardiology (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • eScholarship (California Digital Library) (submittedVersion)
Funders
  • National Institutes of Health (UL1TR002541, 5t32hl069749-20)
  • National Heart, Lung, and Blood Institute (T32-HL069749)
  • National Center for Advancing Translational Sciences
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart rate and cardiovascular health
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
Keywords
heart failure with reduced ejection fraction, guideline-directed medical therapy, ACE inhibitors, angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitors, beta-blockers, mineralocorticoid receptor antagonists, drug discontinuation, dose changes, quality of life, functional class, prior hospitalization
MeSH terms
Aged, Dose-Response Relationship, Drug, Drug Therapy, Combination, Female, Heart Failure, Humans, Male, Middle Aged, Prospective Studies, Quality of Life, Stroke Volume, Ventricular Dysfunction, Left

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