Frailer heart failure patients less likely to receive guideline-recommended therapy

Guideline-recommended therapies for heart failure with reduced ejection fraction may be underprescribed in patients with physical frailty, according to a recent study.

Researchers analyzed patients from FLAGSHIP (Multicentre Prospective Cohort Study to Develop Frailty-Based Prognostic Criteria for Heart Failure Patients) to evaluate use of drugs for heart failure according to physical frailty status. Patients were divided into frailty categories using grip strength, walking speed, a score measuring self-efficacy for walking, and a score measuring performance of activities of daily living. The results were published June 10 by the Journal of the American Heart Association.

A total of 1,041 patients were included in the analysis (mean age, 70 years; 73% male). Three hundred seventy-one were assigned to physical frailty category I, with another 275 patients in category II, 224 in category III, and 171 in category IV. Overall prescription rates of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and mineralocorticoid receptor antagonists were 69.7%, 87.8%, and 51.9%, respectively. The proportion of patients receiving all three drug classes decreased as physical frailty increased (40.2% in category I patients vs. 23.4% in category IV patients; P<0.001 for trend).

Adjusted analyses found that severity of physical frailty was an independent predictor for nonuse of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and beta-blockers (odds ratios [ORs], 1.23 [95% CI, 1.05 to 1.43] and 1.32 [95% CI, 1.06 to 1.64], respectively, per one-category increase) but not mineralocorticoid receptor antagonists (OR, 0.97; 95% CI, 0.84 to 1.12). In a multivariate Cox proportional hazards model, risk for the study's primary outcome, a composite of all-cause death or heart failure rehospitalization up to two years after discharge, was higher in patients receiving no drugs or one drug than in those receiving three drugs, both in physical frailty categories I and II (hazard ratio [HR], 1.80; 95% CI, 1.08 to 2.98) and in categories III and IV (HR, 1.53; 95% CI, 1.01 to 2.32).

The researchers noted that data were not available on whether drugs were contraindicated and that the study was conducted before sacubitril/valsartan and sodium-glucose cotransporter-2 inhibitors were approved, among other limitations. They concluded that in patients with heart failure with reduced ejection fraction, guideline-recommended therapy became less common as physical frailty increased and that physical frailty was an independent predictor of drug use in a multivariate model that included age and renal function. “Suboptimal use of medical treatment was associated with a worse prognosis, regardless of the severity of physical frailty. An effective strategy to improve medical therapy, accounting for physical frailty, is urgently needed,” they wrote.