Variation in use and dosing escalation of renin angiotensin system, mineralocorticoid receptor antagonist, angiotensin receptor neprilysin inhibitor and beta-blocker therapies in heart failure and reduced ejection fraction: Association of comorbidities

Background In patients with heart failure and reduced ejection fraction (HFrEF), angiotensin converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), or angiotensin receptor neprilysin inhibitor (ARNI), mineralocorticoid receptor antagonists (MRA), and beta-blockers (beta B) are underutilized. It is unknown if patients with and without comorbidities have similar ACEi/ARB/ARNI, MRA, and beta B prescription patterns. Methods Baseline data from the CHAMP-HF (Change the Management of Patients with Heart Failure) registry were categorized by history of atrial fibrillation, asthma/chronic lung disease, obstructive sleep apnea, and depression. Using multivariate hierarchical logistic models, associations of ACEi/ARB/ARNI, MRA and beta B medication use and dose by comorbidities were assessed after adjusting for patient characteristics. Results Of 4,815 HFrEF patients from 152 CHAMP-HF sites, ACEi/ARB/ARNI use was lower in patients with more comorbidities, and generally, MRA use was low and beta B use was high. In adjusted analyses, patients with HFrEF and comorbid obstructive sleep apnea, vs. without, were more likely to be prescribed ARNI (OR [95% CI]: 1.25 [1.00, 1.55]); P= .047 and MRA (1.31 [1.11, 1.55]); P= .002 and less likely to be prescribed ACEi (0.74 [0.63, 0.88]); P < .001. Patients with atrial fibrillation, vs. without, were less likely to receive ACEi/ARB (0.82 [0.71, 0.95]); P= .006 and any study medication (0.81 [0.67, 0.97]); P= .020. Comorbid lung disease and history of depression were not associated with HFrEF prescriptions. Conclusions Renin-angiotensin-aldosterone blockade therapy prescription and dose varied by comorbidity status, but beta B therapy did not. In quality efforts, leaders need to consider use and dosing of prescriptions in light of prevalent comorbidities.

Automated summary

In HFrEF patients, those with comorbidities were less likely to use ACEi/ARB/ARNI, while patients with obstructive sleep apnea were more likely to be prescribed ARNI and MRA. Patients with atrial fibrillation were less likely to receive ACEi/ARB and any study medication.