Outcomes with guideline-directed medical therapy and cardiac implantable electronic device therapies for patients with heart failure with reduced ejection fraction

John L Mignone; Kevin M Alexander; Michael Dobbles; Kyle Eberst; Gregg C Fonarow; Kenneth A Ellenbogen

doi:10.1016/j.hroo.2024.01.004

Outcomes with guideline-directed medical therapy and cardiac implantable electronic device therapies for patients with heart failure with reduced ejection fraction

Heart Rhythm O2. 2024 Jan 24;5(3):168-173. doi: 10.1016/j.hroo.2024.01.004. eCollection 2024 Mar.

Authors

John L Mignone¹, Kevin M Alexander², Michael Dobbles³, Kyle Eberst³, Gregg C Fonarow⁴, Kenneth A Ellenbogen⁵

Affiliations

¹ Division of Cardiology, Swedish Medical Center, Seattle, Washington.
² Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California.
³ egnite, Inc., Aliso Viejo, California.
⁴ Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, Los Angeles, California.
⁵ Department of Cardiology, Virginia Commonwealth School of Medicine, Richmond, Virginia.

Abstract

Background: Limited real-world evidence exists for outcomes with contemporary guideline-directed medical therapy (GDMT) or GDMT with implantable cardioverter-defibrillator (ICD)/cardiac resynchronization therapy defibrillator (CRT-D) therapy for patients with heart failure with reduced ejection fraction (HFrEF) and left ventricular ejection fraction (LVEF) ≤35%.

Objective: The present study aimed to assess survival associated with GDMT or GDMT with ICD/CRT-D therapy.

Methods: This retrospective observational study included real-world de-identified data from January 1, 2016, to December 19, 2023, from 24 U.S. institutions per participating institutional agreements (egnite Database; egnite, Inc.). Patients with a diagnosis of HFrEF and an echocardiographic study documenting LVEF ≤35% were included for analysis.

Results: Of 43,591 patients with eligible index event of LVEF ≤35%, prescription history through ≥1 year preindex, and no ICD/CRT-D therapy preindex, mean ± standard deviation age at index was 71.2 ± 13.2 years; 14,805 (34.0%) patients were female. At 24 months, an estimated 99.1% (95% confidence interval [CI] 99.0%-99.2%), 89.9% (95% CI 89.7%-90.1%), 54.8% (95% CI 54.4%-55.2%), and 17.2% (95% CI 16.9%-17.5%), had ≥1, 2, 3, or all 4 GDMT classes prescribed, respectively; an estimated 15.7% (95% CI 15.3%-16.1%) had device placement. Of those without a device, by 24 months, an estimated 45.1% (95% CI 44.4%-45.7%) had a documented LVEF >35%. Counts of GDMT classes prescribed as well as ICD/CRT-D device therapy were associated with lower mortality risk in this population, even after adjustment for patient age, sex, and comorbidities.

Conclusion: Both GDMT classes prescribed and device therapy were independently associated with lower mortality risk, even in the presence of more GDMT options for this more contemporary population.

Keywords: Cardiac resynchronization therapy; Guideline-directed medical therapy; Heart failure with reduced ejection fraction; Implantable cardioverter-defibrillators; Therapy optimization.