The Impact Of Increased Early Utilization Of Angiotensin Receptor Neprilysin Inhibitor (ARNi) And Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2i) In New Onset And Chronic HFrEF

Background

Despite strong evidence of randomized clinical trials on GDMT for HFrEF in improving mortality and outcomes and reducing HF-related hospitalization, we continue to experience suboptimal use of GDMT. The beneficial medical effects of the 4 pillars of HFrEF cannot be ignored. Considerable efforts, such as guidelines and quality improvement (QI) initiatives, are implemented to mitigate the gaps, and results remain unsatisfactory. Aggressive initiation of GDMT should be a high priority.

Purpose

We analyzed the impact of early GDMT initiation with intensified use of ARNi and SGLT2 in new-onset and chronic HFrEF patients with ischemic and nonischemic cardiomyopathy.

Setting/Population

From 2020 to 2023, 284 patients with HFrEF were enrolled in the GDMT optimization program as a QI initiative led by HF NP and pharmacist.

Method/Process

Patients were followed until they achieved the target or maximum tolerated dose of triple or quadruple therapy. Data collected included echocardiography, laboratory values, NYHA, and HF-related hospital readmissions. Follow-up echocardiography was completed between 3 and 6 months, and HF-related readmission was assessed up to 6 months after completion of the program.

Outcome Measures

Among the participants, 94.9% were enrolled within 3 months after being evaluated in the HF clinic. The average age was 64; 70% were male. There were more patients with new onset HF (55%), and the majority were nonischemic (62.3%). Upon completion, there was a similar increase in both groups of those who were on triple and quadruple therapy. The use of ARNi (79.2% vs 84.9%) and SGLT2i (64.8% vs 65.6%) was higher in the two groups at the end of evaluation. A higher percentage of the new onset group had improvement of LVEF, and their absolute degree of improvement was also greater. NYHA Class improved in both groups over the course of therapy. A reduction of BNP was observed, and HF-related readmissions were significantly lower in the new-onset (7.5%) vs the chronic group (19.2%).

Practical Implications

The outcome of intensified use of ARNi and SGLT2i underscores the urgency of initiating treatment immediately after diagnosis of HFrEF. Despite etiology, early initiation of GDMT in newly diagnosed HFrEF demonstrates a greater improvement of LVEF, reduction in BNP, and HF-related readmission compared to chronic HFrEF.