Contemporary guideline-directed medical therapy in de novo, chronic, and worsening heart failure patients: First data from the TITRATE-HF study.

AIMS: Despite clear guideline recommendations for initiating four drug classes in all patients with heart failure (HF) with reduced ejection fraction (HFrEF) and the availability of rapid titration schemes, information on real-world implementation lags behind. Closely following the 2021 ESC HF guidelines and 2023 focused update, the TITRATE-HF study started to prospectively investigate the use, sequencing, and titration of guideline-directed medical therapy (GDMT) in HF patients, including the identification of implementation barriers. METHODS AND RESULTS: TITRATE-HF is an ongoing long-term HF registry conducted in the Netherlands. Overall, 4288 patients from 48 hospitals were included. Among these patients, 1732 presented with de novo, 2240 with chronic, and 316 with worsening HF. The median age was 71 years (interquartile range [IQR] 63-78), 29% were female, and median ejection fraction was 35% (IQR 25-40). In total, 44% of chronic and worsening HFrEF patients were prescribed quadruple therapy. However, only 1% of HFrEF patients achieved target dose for all drug classes. In addition, quadruple therapy was more often prescribed to patients treated in a dedicated HF outpatient clinic as compared to a general cardiology outpatient clinic. In each GDMT drug class, 19% to 36% of non-use in HFrEF patients was related to side-effects, intolerances, or contraindications. In the de novo HF cohort, 49% of patients already used one or more GDMT drug classes for other indications than HF. CONCLUSION: This first analysis of the TITRATE-HF study reports relatively high use of GDMT in a contemporary HF cohort, while still showing room for improvement regarding quadruple therapy. Importantly, the use and dose of GDMT were suboptimal, with the reasons often remaining unclear. This underscores the urgency for further optimization of GDMT and implementation strategies within HF management.

Impact of sex-specific target dose in chronic heart failure patients with reduced ejection fraction.

AIMS: A recent study suggested that women with heart failure and heart failure reduced ejection fraction might hypothetically need lower doses of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers ( = renin-angiotensin-system inhibitors) and ß-blockers than men to achieve the best outcome. We assessed the current medical treatment of heart failure reduced ejection fraction in men and women in a large contemporary cohort and address the hypothetical impact of changing treatment levels in women. METHODS: This analysis is part of a large contemporary quality of heart failure care project which includes 5320 (64%) men and 3003 (36%) women with heart failure reduced ejection fraction. Detailed information on heart failure therapy prescription and dosage were collected. RESULTS: Women less often received renin-angiotensin-system inhibitors (79% vs 83%, p < 0.01), but more often ß-blockers (82% vs 79%, p < 0.01) than men. Differences in guideline-recommended target doses between sexes were relatively small. Implementing a hypothetical sex-specific dosing schedule (at 50% of the current recommended dose in the European Society of Cardiology guidelines in women only) would lead to significantly higher levels of women receiving appropriate dosing (ß-blocker 87% vs 54%, p < 0.01; renin-angiotensin-system inhibitor 96% vs 75%, p < 0.01). Most interestingly, the total number of women with >100% of the new hypothetical target dose would be 24% for ß-blockers and 52% for renin-angiotensin-system inhibitors, which can be considered as relatively overdosed. CONCLUSION: In this large contemporary heart failure registry, there were significant but relatively small differences in drug dose between men and women with heart failure reduced ejection fraction. Implementation of the hypothetical sex-specific target dosing schedule would lead to considerably more women adequately treated. In contrast, we identified a group of women who might have been relatively overdosed with increased risk of side-effects and intolerance.

Identifying Reasons for Nonattendance and Noncompletion of Cardiac Rehabilitation: INSIGHTS FROM GERMANY AND THE NETHERLANDS.

PURPOSE: Despite strong recommendations and beneficial health effects of cardiac rehabilitation (CR), participation rates remain low. Little data are available on reasons beyond quantitative factors in the underutilization of CR. The aim of this study was to identify personal reasons for nonattenders and noncompletions of CR among Dutch and German patients with cardiovascular diseases (CVD) eligible for CR. METHODS: Between December 2017 and January 2019, a total of 4265 questionnaires were distributed among eligible patients for CR in the bordering area of the eastern Netherlands and western Germany. Patients were eligible if they had an indication for CR according to national guidelines. Questionnaires were used to assess reasons of nonattendance and noncompletion of CR, when applicable. RESULTS: A total of 1829 patients with CVD completed the questionnaire. Of these, 1278 indicated that they received referral to CR. Despite referral, 192 patients decided not to participate in CR and 88 patients with CVD withdrew from the CR program. The three most reported reasons for nonattendance were as follows: (1) did not need the supervision (56%, n = 108), (2) did not need the CR trajectory (55%, n = 105), and (3) already exercised regularly (39%, n = 74). The most reported reasons for noncompletion were as follows: (1) could no longer participate because of other physical problems (30%, n = 26), (2) did not need the CR trajectory (26%, n = 23), and (3) the CR program was not personal enough (23%, n = 20). CONCLUSIONS: Most patients had motivational or perceptive reasons for nonattendance or noncompletion to CR. These possible misconceptions as well as perceived shortcomings of traditional CR underline the need for adequate motivation, information, and more personalized solutions (eg, eHealth, home-based CR) to increase the uptake and completion of CR.