Guideline Directed Medical Therapy in Patients With Heart Failure

The lack of adherence to Goal-Directed Medical Therapy (GDMT) is a major problem in modern HF care. Despite advances in therapies for those with HF along with well-articulated goals for achieving guideline-directed medical therapy (GDMT) for affected individuals, the treatment of persons with HF lags behind current recommended guideline approaches, with 30% of ambulatory patients with HFrEF not being prescribed angiotensin receptor/neprilysin inhibitors (ARNI), angiotensin converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), or evidence based beta blockers (eBBB) and the majority not receiving target doses of these medications despite lack of medical contraindications. The reasons for gaps in care include hesitancy to change medical programs in ostensibly stable patients, concerns about risk of drug intolerances, worries about drug costs, as well as uncertainty about benefits. Additionally, complexity of medical therapy, rapid evolution in the currently recommended therapeutic options, and challenges in care coordination also result in missed treatment opportunities. Given that most individuals with HF are cared for by specialists other than those trained in advanced HF therapies, this intersection of increasing complexity of care results in substantial gaps in care. The proposed research is to study impact of the GDMT clinic for patients across the spectrum of HF.

Inclusion criteria

• Diagnosis of HF, including new onset disease
• Established cardiovascular follow up at MGH
• Receiving sub-optimal medical care defined as <50% target doses of GDMT agents
• Age ≥18 years
• For HFpEF:

• Presence of structural heart disease (LAVi >34 mL/Kg2, E/e' >14, or LVH)
• Recent HF hospitalization or historical NT-proBNP >300 pg/mL

Exclusion criteria

• Planned referral to the Advanced HF program
• Decompensated HF
• End-stage kidney disease

• eGFR <15 mL/min/1.73m2 or on renal replacement therapy
• Untreated severe valvular heart disease
• Advanced HF

• Inotropic support
• Transplant or MCS planned
• Enrolled in hospice or palliative care
• Life expectancy <12 months due to non-CV disease
• Pericardial constriction
• Hypertrophic cardiomyopathy
• Unwillingness or inability to take GDMT
• Pregnancy or breast feeding