Adoption of Sacubitril/Valsartan Among Patients With Heart Failure With Mildly Reduced or Preserved Ejection Fraction: The Get With The Guidelines-Heart Failure Registry

Pierce, Jacob B.; Li, Zhen; Greiner, Melissa A.; Lippmann, Steven; Hardy, N. Chantelle; Shen, Xian; Stampehl, Mark R.; Mentz, Robert J; Allen, Larry A.; Peterson, Pamela N.; Fonarow, Gregg C.; O’Brien, Emily C.; Greene, Stephen J.

doi:10.1161/circheartfailure.122.010176

Cited by 14 publications

(9 citation statements)

References 3 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…In Reply We thank Sadaniantz et al for their interest in our recent article. 1 We agree that our findings suggest concerning disparities in sodium-glucose cotransporter-2 inhibitor (SGLT2i) use in heart failure with reduced ejection fraction (HFrEF) across several demographic and clinical subgroups. This includes a significant negative association with kidney disease, despite strong clinical trial evidence for substantial kidney benefit with SGLT2i.…”

supporting

confidence: 79%

“…However, more broadly, we found that prescription of SGLT2i did not reach 25% in any demographic subgroup examined in our study. 1 There were more US hospitals discharging zero eligible patients with SGLT2i prescriptions (29 hospitals) than hospitals discharging 50% or more of eligible patients with SGLT2i prescriptions (19 hospitals). Intensive efforts are needed to ensure all eligible patients with HFrEF are treated with SGLT2i and other life-saving therapies.…”

mentioning

confidence: 99%

See 1 more Smart Citation

Identifying Barriers to Initiation of Sodium-Glucose Cotransporter-2 Inhibitor Therapy in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction

Sadaniantz,

Shih,

Kovell

2023

JAMA Cardiol

View full text Add to dashboard Cite

To the Editor We read with great interest the article by Pierce et al, 1 which found that only 1 in 5 patients hospitalized with heart failure with reduced ejection fraction (HFrEF) in the US was prescribed sodium-glucose cotransporter-2 inhibitor (SGLT2i) at discharge. This is similar to the slow adoption of angiotensin receptor-neprilysin inhibitors (ARNIs), where at 3 years after US Federal Drug Administration approval, less than 20% of eligible patients were prescribed ARNI at discharge. This contrasts current European Society of Cardiology 2021 guidelines and American Heart Association/American College of Cardiology/ Heart Failure Society of America 2022 guidelines for management of HFrEF, which predated this current study, wherein a grade 1A recommendation was given for patients with HFrEF to prevent heart failure hospitalization and cardiovascular death.Notably, this study showed that kidney insufficiency was strongly negatively associated with SGLT2i prescription (odds ratio, 0.78; 95% CI, 0.72-0.85). 1 This is a concerning trend, especially given the findings of Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (included glomerular filtration rate of ≥25 or ≤75 mL/min/1.73 m 2 ) and Study of Heart and Kidney Protection with Empagliflozin (included glomerular filtration rate ≥20 and <45 mL/min/1.73 m 2 or ≥45 mL/ min/1.73 m 2 with increased urinary albumin/creatinine ratio) showing nephroprotective effects of SGLT2i. We wonder if the authors may be able to comment on the stages of chronic kidney disease and their associations with SGLT2i prescriptions on discharge to determine if this negative association exists at all stages of chronic kidney disease.We also are interested in the findings that women were less likely to receive SGLT2i prescriptions (odds ratio, 0.93; 95% CI, 0.88-0.98). 1 This sex difference has been replicated in studies examining SGLT2i prescriptions in type 2 diabetes 2 and the use of both SGLT2is and glucagonlike peptide-1 agonists in both cardiovascular disease and type 2 diabetes. 3 Data from review of thrombolysis in myocardial infarction trials have shown that women remain at higher odds of permanent drug discon-tinuation compared with men. 4 There were other concerning disparities noted in the use of SGLT2i with regards to age and race. We wonder whether the authors may be able to comment on any underlying reasons that may explain these prescribing differences with regards to race and ethnicity, age, and sex.Lastly, this study found lower rates of SGLT2i use in hospitals that were rural, nonteaching, and without interventional cardiac catheterization or heart transplant services. Have the authors considered why such institutiondependent disparities exist? Perhaps hospitals with teaching services or transplant programs have more specialized heart failure programs and pharmacists to allow for greater SGLT2i implementation in eligible patients.

show abstract

supporting

confidence: 79%

mentioning

confidence: 99%

Identifying Barriers to Initiation of Sodium-Glucose Cotransporter-2 Inhibitor Therapy in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction

Sadaniantz,

Shih,

Kovell

2023

JAMA Cardiol

View full text Add to dashboard Cite

show abstract

“…[5][6][7] Prior studies of other therapies proven to reduce mortality and morbidity in HFrEF have observed slow and varied adoption within routine clinical practice, resulting in potentially preventable deaths and hospitalizations. [8][9][10][11][12] At the same time, SGLT2i possess unique features that may favor improved early implementation relative to prior therapies, including simplicity of use (1 dose, once daily administration), minimal effect on blood pressure, and separate guideline recommendations for common comorbidities, including type 2 diabetes (T2D) and chronic kidney disease (CKD). 13,14 Nonetheless, US nationwide utilization of SGLT2i therapy among eligible patients with HFrEF has not been well characterized.…”

mentioning

confidence: 99%

Contemporary Use of Sodium-Glucose Cotransporter-2 Inhibitor Therapy Among Patients Hospitalized for Heart Failure With Reduced Ejection Fraction in the US

et al. 2023

Self Cite

View full text Add to dashboard Cite

ImportanceClinical guidelines for patients with heart failure with reduced ejection fraction (HFrEF) strongly recommend treatment with a sodium-glucose cotransporter-2 inhibitor (SGLT2i) to reduce cardiovascular mortality or HF hospitalization. Nationwide adoption of SGLT2i for HFrEF in the US is unknown.ObjectiveTo characterize patterns of SGLT2i use among eligible US patients hospitalized for HFrEF.Design, Setting, and ParticipantsThis retrospective cohort study analyzed 49 399 patients hospitalized for HFrEF across 489 sites in the Get With The Guidelines–Heart Failure (GWTG-HF) registry between July 1, 2021, and June 30, 2022. Patients with an estimated glomerular filtration rate less than 20 mL/min/1.73 m2, type 1 diabetes, and previous intolerance to SGLT2i were excluded.Main Outcomes and MeasuresPatient-level and hospital-level prescription of SGLT2i at hospital discharge.ResultsOf 49 399 included patients, 16 548 (33.5%) were female, and the median (IQR) age was 67 (56-78) years. Overall, 9988 patients (20.2%) were prescribed an SGLT2i. SGLT2i prescription was less likely among patients with chronic kidney disease (CKD; 4550 of 24 437 [18.6%] vs 5438 of 24 962 [21.8%]; P &lt; .001) but more likely among patients with type 2 diabetes (T2D; 5721 of 21 830 [26.2%] vs 4262 of 27 545 [15.5%]; P &lt; .001) and those with both T2D and CKD (2905 of 12 236 [23.7%] vs 7078 vs 37 139 [19.1%]; P &lt; .001). Patients prescribed SGLT2i therapy were more likely to be prescribed background triple therapy with an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor–neprilysin inhibitor, β-blocker, and mineralocorticoid receptor antagonist (4624 of 9988 [46.3%] vs 10 880 of 39 411 [27.6%]; P &lt; .001), and 4624 of 49 399 total study patients (9.4%) were discharged with prescriptions for quadruple medical therapy including SGLT2i. Among 461 hospitals with 10 or more eligible discharges, 19 hospitals (4.1%) discharged 50% or more of patients with prescriptions for SGLT2i, whereas 344 hospitals (74.6%) discharged less than 25% of patients with prescriptions for SGLT2i (including 29 [6.3%] that discharged zero patients with SGLT2i prescriptions). There was high between-hospital variance in the rate of SGLT2i prescription in unadjusted models (median odds ratio, 2.53; 95% CI, 2.36-2.74) and after adjustment for patient and hospital characteristics (median odds ratio, 2.51; 95% CI, 2.34-2.71).Conclusions and RelevanceIn this study, prescription of SGLT2i at hospital discharge among eligible patients with HFrEF was low, including among patients with comorbid CKD and T2D who have multiple indications for therapy, with substantial variation among US hospitals. Further efforts are needed to overcome implementation barriers and improve use of SGLT2i among patients with HFrEF.

show abstract

“… 13 In those countries where sacubitril/valsartan has been approved for use in chronic HF at higher LVEF, initial uptake has been variable. 24 These mixed guideline recommendations and variable clinical practice patterns may reflect residual uncertainties about the role of sacubitril/valsartan in HF with mildly reduced or preserved ejection fraction. These pooled analyses may bolster the confidence in cardiovascular and renal event reduction with sacubitril/valsartan in patients with HF with mildly reduced or preserved ejection fraction, particularly in those with LVEF below normal.…”

Section: Discussionmentioning

confidence: 99%

Sacubitril/valsartan in heart failure with mildly reduced or preserved ejection fraction: a pre-specified participant-level pooled analysis of PARAGLIDE-HF and PARAGON-HF

Vaduganathan

Mentz

Claggett

et al. 2023

European Heart Journal

View full text Add to dashboard Cite

Background and aims The PARAGLIDE-HF trial demonstrated reductions in natriuretic peptides with sacubitril/valsartan compared with valsartan in patients with heart failure (HF) with mildly reduced or preserved ejection fraction who had a recent worsening HF event, but was not adequately powered to examine clinical outcomes. PARAGON-HF included a subset of PARAGLIDE-HF-like patients who were recently hospitalized for HF. Participant-level data from PARAGLIDE-HF and PARAGON-HF were pooled to better estimate the efficacy and safety of sacubitril/valsartan in reducing cardiovascular and renal events in HF with mildly reduced or preserved ejection fraction. Methods Both PARAGLIDE-HF and PARAGON-HF were multicenter, double-blind, randomized, active-controlled trials of sacubitril/valsartan vs. valsartan in patients with HF with mildly reduced or preserved left ventricular ejection fraction (LVEF >40% in PARAGLIDE-HF and ≥45% in PARAGON-HF). In the pre-specified primary analysis, we pooled participants in PARAGLIDE-HF (all of whom were enrolled during or within 30 days of a worsening HF event) with a ‘PARAGLIDE-like’ subset of PARAGON-HF (those hospitalized for HF within 30 days). We also pooled the entire PARAGLIDE-HF and PARAGON-HF populations for a broader context. The primary endpoint for this analysis was the composite of total worsening HF events (including first and recurrent HF hospitalizations and urgent visits) and cardiovascular death. The secondary endpoint was the pre-specified renal composite endpoint for both studies (≥50% decline in estimated glomerular filtration rate from baseline, end-stage renal disease, or renal death). Results Compared with valsartan, sacubitril/valsartan significantly reduced total worsening HF events and cardiovascular death in both the primary pooled analysis of participants with recent worsening HF (n=1,088; rate ratio [RR] 0.78; 95% confidence interval [CI] 0.61-0.99; P=0.042) and in the pooled analysis of all participants (n=5,262; RR 0.86; 95% CI: 0.75-0.98; P=0.027). In the pooled analysis of all participants, first nominal statistical significance was reached by day 9 after randomization and treatment benefits were larger in those with LVEF ≤60% (RR 0.78; 95% CI 0.66-0.91) compared with those with LVEF >60% (RR 1.09; 95% CI 0.86-1.40; Pinteraction=0.021). Sacubitril/valsartan was also associated with lower rates of the renal composite endpoint in the primary pooled analysis (hazard ratio [HR] 0.67; 95% CI 0.43-1.05; P=0.080) and the pooled analysis of all participants (HR 0.60; 95% CI 0.44-0.83; P=0.002). Conclusions In pooled analyses of PARAGLIDE-HF and PARAGON-HF, sacubitril/valsartan reduced cardiovascular and renal events among patients with HF with mildly reduced or preserved ejection fraction. These data provide support for use of sacubitril/valsartan in patients with HF with mildly reduced or preserved ejection fraction, particularly among those with an LVEF below normal, regardless of care setting.

show abstract

Adoption of Sacubitril/Valsartan Among Patients With Heart Failure With Mildly Reduced or Preserved Ejection Fraction: The Get With The Guidelines-Heart Failure Registry

Cited by 14 publications

References 3 publications

Identifying Barriers to Initiation of Sodium-Glucose Cotransporter-2 Inhibitor Therapy in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction

Identifying Barriers to Initiation of Sodium-Glucose Cotransporter-2 Inhibitor Therapy in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction

Contemporary Use of Sodium-Glucose Cotransporter-2 Inhibitor Therapy Among Patients Hospitalized for Heart Failure With Reduced Ejection Fraction in the US

Sacubitril/valsartan in heart failure with mildly reduced or preserved ejection fraction: a pre-specified participant-level pooled analysis of PARAGLIDE-HF and PARAGON-HF

Contact Info

Product

Resources

About