Residual Risk in Heart Failure and the Need for Simultaneous Implementation and Innovation

Abstract

Therapeutic innovations have improved heart failure (HF) management.Optimal guideline-directed medical therapy (GDMT) can reduce the relative risk of cardiovascular mortality by 75%, with an absolute risk reduction of 25% over 2 years, translating into a number needed to treat of only 4 for patients with HF and reduced ejection fraction (HFrEF). 1 Recently, two trials with sodium-glucose cotransporter 2 inhibitors (SGLT2i) have shown a reduced risk of time to cardiovascular death or HF hospitalization in patients with HF and mildly reduced or preserved ejection fraction (HFmrEF/HFpEF). 2,3Parallel advances have occurred with device-based therapies for HFrEF as well. Treatment patterns and urgency for implementationDespite this, the outcomes of patients with HF remain suboptimal.This is attributed to poor uptake of GDMT. Lee et al. 4 assessed the use of therapies for HFrEF in relation to predicted mortality risk.Despite the proven benefits of angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs) and beta-blockers, there were large treatment gaps in use of these therapies in eligible patients with a marked discordance in the risk versus treatment rates.With increasing mortality risk, discharge prescription rates of these therapies decreased.More than a decade later, the trends of underdosing and undertreatment of HF therapies remain.In 2019, Greene et al. 5 showed that 1% of eligible patients with HFrEF simultaneously received ACEi/ARB/angiotensin receptor-neprilysin inhibitor (ARNi), beta-blocker, and mineralocorticoid receptor antagonist (MRA) at target doses.This underscores the importance of efforts to increase implementation of GDMT and conduct clinical trials to evaluate the effectiveness of implementation strategies that hold promise to improve outcomes.Implementation of GDMT could be improved though the use of performance improvement systems, structured early and intensive post-hospital discharge follow-up of

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