In HFrEF, therapy in patients with frailty often not optimized despite high risk
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In patients with HF with reduced ejection fraction, those with frailty had elevated risk for poor outcomes but less likelihood of being on optimal guideline-directed medical therapy, according to new data from the GUIDE-IT trial.
As Healio previously reported, in the main results of GUIDE-IT, a strategy guided by N-terminal pro-B-type natriuretic peptide levels did not benefit patients with HFrEF more than the usual care. For the present post hoc analysis published in JACC: Heart Failure, researchers stratified the cohort into three groups based on frailty index score and compared frailty status with clinical outcomes and use of optimal guideline-directed medical therapy over time.
The cohort consisted of 879 patients (mean age, 63 years; 32% women), of whom 56.3% had a high frailty burden, defined as a frailty index score of more than 0.31. Optimal guideline-directed medical therapy was defined as use of beta-blockers, ACE inhibitors/angiotensin receptor blockers and mineralocorticoid receptor antagonists.
Patients with a high frailty burden had elevated risk for HF hospitalization or death compared with nonfrail patients (adjusted HR = 1.76; 95% CI, 1.2-2.58), Muhammad Shahzeb Khan, MD, MSc, cardiology fellow at Duke University School of Medicine, and colleagues wrote.
Between baseline and 1 year, in patients without frailty, there was an increase in use of optimal guideline-directed medical triple therapy (from 9.8% to 28.4%) and in use of double therapy (from 38.7% to 52.6%), whereas the increases observed in patients with high frailty burden were smaller (triple therapy, from 9.3% to 17.7%; double therapy, from 31.7% to 40.5%; P for interaction between frailty class and time < .001), according to the researchers.
“Our findings suggest that HFrEF patients with a higher burden of frailty are more likely to experience underutilization of guideline-directed medical therapy, despite being at higher risk for adverse clinical outcomes,” Khan and colleagues wrote.
In a related editorial, Nathan Mewton, MD, PhD, and Laurent Sebbag, MD, PhD, both from Cardiovascular Hospital Louis Pradel, Heart Failure Department and Clinical Investigation Center, Inserm 1407 and Inserm Carmen 1060, University Claude Bernard Lyon 1, Hospices Civils de Lyon, France, wrote the study shows that “we do exactly the opposite of what we are supposed to do in patients that need it the most.”
The study provides “encouragement to challenge the way we optimize HF therapies in our patients on a daily basis,” they wrote. “On every visit we should seize the opportunity for optimization.”
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