(P177) REAL-WORLD ELIGIBILITY FOR GUIDELINE DIRECTED MEDICAL THERAPY ACROSS THE SPECTRUM OF LEFT VENTRICULAR EJECTION FRACTION: RESULTS FROM VANCOUVER COASTAL ACUTE HEART FAILURE (VOCAL-AHF) REGISTRY

Background: There is growing evidence that simultaneous and rapid introduction of guideline-directed medical therapy (GDMT) after stabilization of an acute heart failure (AHF) episode improves morbidity and survival. However, there remains significant therapeutic hesitancy in initiating GDMT during hospitalization due to perceived risk of intolerance or adverse effects. In this study, we evaluated eligibility for GDMT across the spectrum of left ventricular ejection fraction (LVEF) in a contemporary AHF population.

METHODS AND RESULTS: Data from VancOuver CoastAL Acute Heart Failure Audit (VOCAL-AHF) of patients discharged from hospital with a primary diagnosis of HF was retrospectively analyzed between April 2015 and March 2019. Eligibility for GDMT was determined based on major society guidelines including the 2021 Canadian Cardiovascular Society (CCS) and 2022 American College of Cardiology (ACC) updated HF guidelines. HF with reduced EF (HFrEF) was defined as LVEF ≤ 40%, HF with mildly reduced EF (HFmrEF) as LVEF 41-49%, and HF with preserved EF (HFpEF) as LVEF ≥ 50%.

Among 1866 unique admissions with acute HF, 1587 patients had accurate LVEF assessment. There were 782 patients with HFrEF (49.3%), 132 with HFmrEF (8.3%), and 673 with HFpEF (42.4%). Mean age overall was 73±15 years, 58% of patients were male, and most common comorbidities were hypertension (72%), atrial fibrillation (54%), and diabetes (37%). In HFrEF, eligibility for angiotensin receptor–neprilysin inhibitors (ARNI) was 64.4%, β-blockers 89.6%, mineralocorticoid receptor antagonists (MRA) 73.8%, and sodium/glucose cotransporter 2 inhibitor (SGLT2i) 82.2%. Additionally, 38.7% and 10.9% of HFrEF patients were eligible for vericiguat and ivabradine, respectively. In HFmrEF, 56.8% were eligible for ARNI, 94.6% for β-blockers, 60.6% for MRA, and 66.7% for SGLT2i. Eligibility for GDMT in HFpEF included: 48.6% for ARNI, 62.6% for MRA, and 73.1% for SGLT2i. Eligibility for simultaneous initiation of various combinations of HF pharmacological pillars across a spectrum of LVEF phenotypes is illustrated in Figure 1.

Conclusion: Most patients with AHF with any LVEF are eligible for simultaneous and intensive implementation of GDMT at hospital discharge. There should be urgency to rapidly initiate these disease-modifying HF medications in hospital to improve outcomes.