The treatment decisions made immediately following hospitalisation for heart failure (hHF) are critically important for patient outcomes.1 Although there are prognostic advantages to initiating long-term heart failure (HF) treatment, new real-world evidence (RWE) highlights the lack of urgency seen at this critical juncture in the care of patients with HF.2-4 This is seen despite knowing that timely intervention can mitigate the high risk of clinical events after a HF diagnosis.
The current state of treatment in patients with HF
HF is a chronic and life-threatening disease and the leading cause of hospitalisation for those over the age of 65.5,6 Although life expectancy of patients with HF has improved thanks to advanced treatment options, mortality rates are still on the rise.1,7 Approximately half of patients diagnosed with HF are expected to die within five years, which matches mortality rates of some of the most common types of cancer in both men (prostate and bladder cancers) and women (breast cancers).8,9 Heart failure often progresses following hHF and with no available cure, there is a critical need to evolve effective treatment practices to care for patients living with HF as soon as they are diagnosed.1,7,10
In current guideline-directed medical therapy (GDMT), optimal use of HF medicines in treating patients recently hospitalised for HF relies on sequential dose titration of several treatment types until reaching the targeted, highest tolerable dose.11,12 However, real-life patterns of newly initiated GDMT in this patient population indicate that there are challenges, such as adverse reactions or low tolerability, that make maintaining a complex treatment regimen for an extended period of time difficult.13,14
Using RWE to understand patterns in HF management
Through analyses of healthcare databases in Sweden, the UK and the US, a new RWE study has shown that despite the high risk of clinical events after hHF, many patients who begin GDMT do not end up receiving the optimal dose of HF medications or discontinue treatment too soon.4 Although dosing at the start of GDMT aligns with the treatment guidelines, only 10-30% of patients reach the optimal dose, and 24-55% stop taking the medication within one year. Optimal use of GDMT calls for the initiation of multiple types of HF medicines over time and consideration of the proper sequencing of these drugs. This process often results in treatment delays and can prevent patients from getting the life-saving medications they need.4
Despite the positive link between proper use of GDMT dosing and better patient outcomes, it is often not put into practice long term.4,12,15 With high risk of readmission and death during the titration process, failure to reach the target dosage or premature discontinuation of HF drugs can have fatal consequences. Moving away from a lengthy sequential approach toward more agile, on-time treatment decisions is crucial for improving patient outcomes.4
RWE and optimising patient care
The real-world insights gathered from this study present us with an opportunity to act and improve the treatment of HF and transform clinical practice.4 These results, recently published in the European Journal of Heart Failure, show that barriers to proper treatment and management of HF were consistently found across three countries with different healthcare systems and economies – indicating that this is representative of a wider global situation.
At AstraZeneca, we are dedicated to tackling this leading cause of death and pushing the boundaries of HF treatment to improve the lives of patients with HF and their families. We believe that innovative means of generating evidence, like RWE, allow us the opportunity to understand the status of HF management in the real world, and can provide valuable information to supplement traditional clinical research. Our teams are consistently looking for opportunities to leverage patient databases to address real-life scientific questions. This better understanding of healthcare practice around the world will allow us to support healthcare communities and improve our ability to care for patient populations, like those living with HF.
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2. Ouwerkerk W, Voors AA, Anker SD, Cleland JG, Dickstein K, Filippatos G, et al. Determinants and clinical outcome of uptitration of ACE-inhibitors and beta-blockers in patients with heart failure: a prospective European study. Eur Heart J. 2017 Jun 21;38(24):1883–90.
3. Komajda M, Cowie MR, Tavazzi L, Ponikowski P, Anker SD, Filippatos GS. Physicians’ guideline adherence is associated with better prognosis in outpatients with heart failure with reduced ejection fraction: the QUALIFY international registry. European Journal of Heart Failure. 2017;19(11):1414–23.
4. Savarese G, Bodegard J, Norhammar A, Sartipy P, Thuresson M, Cowie MR, et al. Heart Failure Drug Titration, Discontinuation, Mortality and Heart Failure Hospitalization Risk: A Multinational Observational Study (US, UK and Sweden). Eur J Heart Fail. 2021 Jun 15 [Epub ahead of print]
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11. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. European Heart Journal. 2016 Jul 14;37(27):2129–200.
12. WRITING COMMITTEE MEMBERS, Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, et al. 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2016 Sep 27;134(13):e282-293.
13. Maggioni AP, Anker SD, Dahlström U, Filippatos G, Ponikowski P, Zannad F, et al. Are hospitalized or ambulatory patients with heart failure treated in accordance with European Society of Cardiology guidelines? Evidence from 12,440 patients of the ESC Heart Failure Long-Term Registry. Eur J Heart Fail. 2013 Oct;15(10):1173–84.
14. Fu M, Vedin O, Svennblad B, Lampa E, Johansson D, Dahlström U, et al. Implementation of sacubitril/valsartan in Sweden: clinical characteristics, titration patterns, and determinants. ESC Heart Fail. 2020 Sep 3;7(6):3633–43.
15. Greene SJ, Fonarow GC, DeVore AD, Sharma PP, Vaduganathan M, Albert NM, et al. Titration of Medical Therapy for Heart Failure With Reduced Ejection Fraction. J Am Coll Cardiol. 2019 May 21;73(19):2365–83.
Veeva ID: Z4-34971
Date of Preparation: June 2021