Ravi B Patel1, Gregg C Fonarow2, Stephen J Greene3, Shuaiqi Zhang4, Brooke Alhanti4, Adam D DeVore5, Javed Butler6, Paul A Heidenreich7, Joanna C Huang8, Michelle M Kittleson9, Karen E Joynt Maddox10, James J McDermott8, Anjali Tiku Owens11, Pamela N Peterson12, Scott D Solomon13, Orly Vardeny14, Clyde W Yancy15, Muthiah Vaduganathan16. 1. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA. Electronic address: https://twitter.com/RBPatelMD. 2. Ahmanson-University of California, Los Angeles Cardiomyopathy Center, University of California-Los Angeles, Los Angeles, California, USA. Electronic address: gfonarow@mednet.ucla.edu. 3. Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA. Electronic address: https://twitter.com/SJGreene_md. 4. Duke Clinical Research Institute, Durham, North Carolina, USA. 5. Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA. Electronic address: https://twitter.com/_adevore. 6. Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA. Electronic address: https://twitter.com/JavedButler1. 7. Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA. 8. AstraZeneca, Wilmington, Delaware, USA. 9. Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, California, USA. Electronic address: https://twitter.com/MKIttlesonMD. 10. Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri, USA. Electronic address: https://twitter.com/kejoynt. 11. Heart and Vascular Center, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address: https://twitter.com/tikuowens. 12. Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA; Department of Medicine, Anschutz Medical Center, Aurora, Colorado, USA. 13. Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. Electronic address: https://twitter.com/scottdsolomon. 14. Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, University of Minnesota, Minnesota, USA. Electronic address: https://twitter.com/orlyvardeny. 15. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA. 16. Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. Electronic address: https://twitter.com/mvaduganathan.
Abstract
BACKGROUND: Few contemporary data exist evaluating care patterns and outcomes in heart failure (HF) across the spectrum of kidney function. OBJECTIVES: This study sought to characterize differences in quality of care and outcomes in patients hospitalized for HF by degree of kidney dysfunction. METHODS: Guideline-directed medical therapies were evaluated among patients hospitalized with HF at 418 sites in the GWTG-HF (Get With The Guidelines-Heart Failure) registry from 2014 to 2019 by discharge CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)-derived estimated glomerular filtration rate (eGFR). We additionally evaluated the risk-adjusted association of admission eGFR with in-hospital mortality. RESULTS: Among 365,494 hospitalizations (age 72 ± 15 years, left ventricular ejection fraction [EF]: 43 ± 17%), median discharge eGFR was 51 ml/min/1.73 m2 (interquartile range: 34 to 72 ml/min/1.73 m2), 234,332 (64%) had eGFR <60 ml/min/1.73 m2, and 18,869 (5%) were on dialysis. eGFR distribution remained stable from 2014 to 2019. Among 157,439 patients with HF with reduced EF (≤40%), discharge guideline-directed medical therapies, including beta-blockers, were lowest in discharge eGFR <30 mL/min/1.73 m2 or dialysis (p < 0.001). "Triple therapy" with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor + beta-blocker + mineralocorticoid receptor antagonist was used in 38%, 33%, 25%, 15%, 5%, and 3% for eGFR ≥90, 60 to 89, 45 to 59, 30 to 44, <30 ml/min/1.73 m2, and dialysis, respectively; p < 0.001. Mortality was higher in a graded fashion at lower admission eGFR groups (1.1%, 1.5%, 2.0%, 3.0%, 5.0%, and 4.2%, respectively; p < 0.001). Steep covariate-adjusted associations between admission eGFR and mortality were observed across EF subgroups, but was slightly stronger for HF with reduced EF compared with HF with mid-range or preserved EF (pinteraction = 0.045). CONCLUSIONS: Despite facing elevated risks of mortality, patients with comorbid HF with reduced EF and kidney disease are not optimally treated with evidence-based medical therapies, even at levels of eGFR where such therapies would not be contraindicated by kidney dysfunction. Further efforts are required to mitigate risk in comorbid HF and kidney disease.
BACKGROUND: Few contemporary data exist evaluating care patterns and outcomes in heart failure (HF) across the spectrum of kidney function. OBJECTIVES: This study sought to characterize differences in quality of care and outcomes in patients hospitalized for HF by degree of kidney dysfunction. METHODS: Guideline-directed medical therapies were evaluated among patients hospitalized with HF at 418 sites in the GWTG-HF (Get With The Guidelines-Heart Failure) registry from 2014 to 2019 by discharge CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)-derived estimated glomerular filtration rate (eGFR). We additionally evaluated the risk-adjusted association of admission eGFR with in-hospital mortality. RESULTS: Among 365,494 hospitalizations (age 72 ± 15 years, left ventricular ejection fraction [EF]: 43 ± 17%), median discharge eGFR was 51 ml/min/1.73 m2 (interquartile range: 34 to 72 ml/min/1.73 m2), 234,332 (64%) had eGFR <60 ml/min/1.73 m2, and 18,869 (5%) were on dialysis. eGFR distribution remained stable from 2014 to 2019. Among 157,439 patients with HF with reduced EF (≤40%), discharge guideline-directed medical therapies, including beta-blockers, were lowest in discharge eGFR <30 mL/min/1.73 m2 or dialysis (p < 0.001). "Triple therapy" with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor + beta-blocker + mineralocorticoid receptor antagonist was used in 38%, 33%, 25%, 15%, 5%, and 3% for eGFR ≥90, 60 to 89, 45 to 59, 30 to 44, <30 ml/min/1.73 m2, and dialysis, respectively; p < 0.001. Mortality was higher in a graded fashion at lower admission eGFR groups (1.1%, 1.5%, 2.0%, 3.0%, 5.0%, and 4.2%, respectively; p < 0.001). Steep covariate-adjusted associations between admission eGFR and mortality were observed across EF subgroups, but was slightly stronger for HF with reduced EF compared with HF with mid-range or preserved EF (pinteraction = 0.045). CONCLUSIONS: Despite facing elevated risks of mortality, patients with comorbid HF with reduced EF and kidney disease are not optimally treated with evidence-based medical therapies, even at levels of eGFR where such therapies would not be contraindicated by kidney dysfunction. Further efforts are required to mitigate risk in comorbid HF and kidney disease.
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