A Survey Of Medical Therapy In Patients With Chronic Heart Failure With Reduced Ejection Fraction

[Background]Heart failure(HF)is a severe or terminal stage of various heart diseases,with a high prevalence rate,re-hospitalization rate and mortality.For patients with Heart failure with reduced ejection fraction(HFrEF),contemporary therapy recommends guideline-directed medical therapy(GDMT).GDMT includes the use of angiotensin converting enzyme inhibitor(ACEI)or angiotensin II receptor blocker(ARB)or angiotensin receptor neprilysin inhibitor(ARNI),combining with beta-blocker and using mineralocorticoid receptor antagonist(MRA)in adaptive patients.Guidelines strongly recommend patients with HFrEF be treated with multiple medications to decrease mortality and re-hospitalization rates and improve clinical outcomes.However,in real-world,the current situation of GDMT of patients with HFrEF is not optimistic.There are big gaps in medical use and dosing persist between the routine clinical practice and the guidelines.At present,the current situation of GDMT for patients with HFrEF in Yunnan is unclear,and the associated factors are rarely reported.[Objective]This study sought to investigate the clinical characteristics and medicine use in patients with HFrEF in some areas of Yunnan,and to expose factors associated with use and dose of HFrEF medications.[Methods]This study was a prospective,observational study.From July 2019 to October 2019,a total of 51 patients with chronic HFrEF who were admitted to the department of cardiology in the first affiliated hospital of kunming medical university were enrolled in study.Baseline clinical data including patient demographics,HF history,laboratory values,electrocardiogram,ultrasonic cardiogram,medicine use were collected during hospitalization.Follow-up was conducted at 3 months after discharge.Medicine use、New York Heart Association functional class、clinical outcomes were collected during follow-up.And factors associated with medication use were examined.[Results]1.Mean age of 51 patients was 58.1 ± 16.7 years,54.9%(28/51)were male,and mean duration of hospitalization was 9.1±3.5 days.Mean left ventricular ejection fraction(LVEF)was 30.4±7.3%.The common causes of HFrEF were dilated cardiomyopathy(35.3%),ischemic cardiomyopathy(23.5%),hypertension(21.6%),valvular heart disease(9.8%)and alcoholic heart disease(3.9%)The common inducements were infection(33.3%),fatigue(27.5%),myocardial ischemia(13.7%),poor medication compliance(9.8%)and arrhythmia(5.9%).The common complications were chronic kidney disease(27.5%),hypertension(19.6%),atrial fibrillation(19.6%),coronary heart disease(17.6%)and thyroid dysfunction(15.7%).2.The use of ACEI/ARB/ARNI,beta-blocker and MRA at discharge were 70.8%、83.3%、89.6%,respectively.60.4%of patients received ACEI/ARB/ARNI and beta-blocker and MRA therapy.When medications were prescribed,44.1%(15/34)of patients received<25%target dose of ACEI/ARB/ARNI,38.2%(13/34)of patients received 25%-49%target dose of ACEI/ARB/ARNI,14.7%(5/34)received 50%-99%target dose of ACEI/ARB/ARNI,2.9%(1/34)received target dose of ACEI.About the dose of beta-blocker,42.5%(17/40)of patients received<25%target dose,42.5%(17/40)of patients received 25%-49%target dose,15.0%(6/40)received 50%-99%target dose,and there were no cases received target dose.All patients received target dose of MRA.3.At discharge,the main reasons for not using ACEI/ARB/ARNI and MRA were renal insufficiency,hyperkalemia,bilateral renal artery stenosis and other contraindications.ACEI/ARB/ARNI not reached target doses due to hypotension.Bradycardia,long RR interval,atrioventricular block and hypotension were the main reasons for not using beta blockers.4.48 patients were followed-up after 3 months.The primary clinical outcomes were death(12.5%),cardiovascular death(10.4%),re-hospitalization(20.8%),and re-hospitalization because of heart failure(10.4%).5.At follow-up after 3 months,the use of ACEI/ARB/ARNI,beta-blocker and MRA were 71.4%、78.6%、81.0%.The utilization rates of beta-blocker and MRA were decreased compared with that of discharge.40.0%(12/30)of patients received<25%target dose of ACEI/ARB/ARNI,40.0%(12/30)of patients received 25%～49%target dose of ACEI/ARB/ARNI,16.7%(5/30)received 50%～99%target dose of ACEI/ARB/ARNI,3.3%(1/30)received target dose of ACEI.About the dose of beta-blocker,45.5%(15/33)of patients received<25%target dose,39.4%(13/33)of patients received 25%～49%target dose,15.1%(5/33)received 50%～99%target dose,and there were no cases received target dose.All patients received target dose of MRA.6.There are many factors associated with GDMT of patients with HFrEF after 3 months.Poor follow-up consciousness,difficulties in purchasing medicines due to remote geographical location,poor medication compliance and anxiety were the main influencing factors.The doctors did not up-regulate the dose of ACEI/ARB/ARNI and beta blockers,which affects the gradual titration of medicines to the target dose.[Conclusions]1.The current situation of GDMT for chronic HFrEF patients in some areas of Yunnan is not optimistic.The utilization rates of ACEI/ARB/ARNI and beta blockers are low,and the dosages are seriously insufficient.There are big gaps in recommendations of the guidelines.2.At discharge,medicines intolerance or contraindications are the main reasons for lower medication utilization or doses of ACEI/ARB/ARNI and beta blockers3.At follow-up,poor follow-up consciousness,difficulties in purchasing medicines due to remote geographical location,poor medication compliance and anxiety associated with negative medical therapy.The doctors did not up-regulate the dose of ACEI/ARB/ARNI and beta blockers,which affects the standardized treatment of medical therapy.