In 2015–19, the use of angiotensin receptor neprilysin inhibitor (ARNI) and guideline-directed medical therapy (GDMT; renin-angiotensin blockers, beta-blockers, and mineralocorticoid receptor antagonists) was low among Medicare beneficiaries with heart failure with reduced ejection fraction (HFrEF), a study shows, particularly those with frailty. “The slow uptake and low utilization of [GDMT] in frail older adults call for an innovative care model to optimize heart failure management in this population,” the authors conclude.
The investigators used Medicare data to determine the proportion of beneficiaries receiving ARNI and GDMT each year by frailty status and assessed the clinical characteristics associated with ARNI initiation: “Among 147,506–180,386 beneficiaries with HFrEF (mean age: 77 years; 27% women; 42.6–49.1% frail) in 2015–2019, the proportion of patients receiving ARNI increased in both non-frail (0.4%–16.4%) and frail (0.3%–13.7%) patients (P for yearly-trend-by-frailty = 0.970). Among those not receiving a renin-angiotensin system blocker, patients with age ≥ 85 years (odds ratio [95% CI], 0.89 [0.80–0.99]), dementia (0.88 [0.81–0.96]), and frailty (0.87 [0.81–0.94]) were less likely to initiate ARNI. The proportion of patients receiving all 3 GDMT classes increased in non-frail patients (22.0%–27.0%) but changed minimally in frail patients (19.6%–21.8%). Regardless of frailty status, treatment with at least 1 class of GDMT was associated with lower death or heart failure hospitalization than no GDMT medications (hazard ratio [95% CI], 0.94 [0.91–0.97], 0.92 [0.89–0.94], 0.94 [0.91–0.97] for 1, 2, and 3 classes, respectively).”