Background: Acute heart failure exacerbations are a leading cause of morbidity and mortality, with high rates of hospitalization and healthcare expenditure. Guideline-directed medical therapy (GDMT) has improved outcomes in heart failure with reduced ejection fraction (HFrEF), improved ejection fraction (HFimpEF), preserved ejection fraction (HFpEF), and moderately reduced ejection fraction (HFmrEF). Recent studies highlight the benefits of GDMT initiation and up-titration during hospitalization. Patients are also more likely to pick up medications from an on-site pharmacy. This study explores GDMT prescribing trends at Thomas Jefferson University Hospital (TJUH) to identify areas for improvement and establish a baseline for evaluating future interventions.
Methods: This retrospective chart review included 73 patients discharged in August 2024 from a Department of Medicine service at TJUH with heart failure requiring intravenous diuretics. Data extraction was conducted manually, and patients were categorized into HFrEF/HFimpEF or HFmrEF/HFpEF. GDMT for HFrEF/HFimpEF was assessed across the “four pillars” (angiotensin receptor-neprilysin inhibitor [ARNi]/angiotensin-converting enzyme inhibitor [ACEi]/angiotensin receptor blocker [ARB], mineralocorticoid receptor antagonist [MRA], sodium-glucose cotransporter 2 inhibitors [SGLT2i], beta blocker [BB]) for home prior-to-admission prescribing, discharge prescribing, and target-dose achievement at discharge. GDMT for HFmrEF/HFpEF focused on SGLT2i. Analysis was performed in Excel.
Results: Of the 73 patients, 40 had HFrEF or HFimpEF. At admission, 6 (15%) were on all four GDMT pillars; 16 (40%) were on SGLT2i, 21 (53%) on ARNi/ACEi/ARB, 13 (33%) on MRA, and 24 (60%) on BB. At discharge, 7 (18%) were on all four pillars; 18 (45%) were on SGLT2i, 20 (50%) on ARNi/ACEi/ARB, 14 (35%) on MRA, and 30 (75%) on BB. None were at target doses for all four pillars, while 2 (5%) reached target doses of ARNi/ACEi/ARB, 14 (35%) for MRA, and 5 (13%) for BB. SGLT2i’s have fixed dosing. Of the 32 patients with HFmrEF or HFpEF, 6 (19%) were on SGLT2i at admission, with no change at discharge. Of the 55 patients discharged home, 19 (29%) had prescriptions sent to the on-site pharmacy.
Conclusions: GDMT prescribing prior to admission and at discharge compares poorly to top performing institutions. Though contraindications make a 100% four-pillar goal unreasonable, among patients with HFrEF and HFimpEF, only 15% were on all four GDMT pillars at admission, with a modest 3% increase at discharge, highlighting significant gaps in outpatient and inpatient care. Utilization of SGLT2is was low and unchanged for HFmrEF/HFpEF and minimally improved for HFrEF/HFimpEF. Beta blockers were the most commonly initiated therapy (15% increase during admission) compared to SGLT2 inhibitors (5%), ARNi/ACEi/ARB (3%), and MRA (2%). Variability in prescribing trends may reflect differences in clinical utility, side effect profiles, or barriers such as cost and preference. More convenient dispensing pharmacy choice may improve adherence. These data emphasize the need for interventions like inpatient protocols, pharmacist-driven management, and enhanced discharge planning including increasing ease of prescription access. We will use this data to implement targeted interventions to improve GDMT prescribing and as a base to which to compare the efficacy of those interventions to iteratively improve the care of this high-risk patient population.