Use of Guideline-Directed Medications for Heart Failure Before Cardioverter-Defibrillator Implantation

Abstract

Background: Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) is recommended before primary prevention implantable cardioverter-defibrillator (ICD) placement. Adherence to this recommendation and associated outcomes are unknown.

Objectives: This study examined the use of GDMT (≥1 prescription filled for both a renin-angiotensin inhibitor [RAI] and a heart failure-approved beta-blocker [HFBB]) within 90 days before primary prevention ICD placement in patients with HFrEF.

Methods: Data from the National Cardiovascular Data Registry ICD Registry were merged with a 40% random sample of Medicare administrative data. Prescription fills for recipients of primary prevention ICD between 2007 and 2011 were examined, analyzing GDMT overall and for each U.S. hospital referral region. We identified characteristics associated with GDMT and the association with 1-year mortality.

Results: Among 19,733 patients with HFrEF and primary prevention ICD, 61.1% filled any GDMT before implantation. Across hospital referral regions, GDMT was applied in 51% to 71%. The strongest predictors of any GDMT included absence of chronic renal disease or nonsustained ventricular tachycardia, low-income prescription benefits subsidy, and less recent left ventricular ejection fraction evaluation. Patients receiving GDMT versus those without had a lower 1-year mortality rate after ICD implantation (11.1% vs. 16.2%), even after adjustment for comorbidities, left ventricular ejection fraction, and functional heart failure class.

Conclusions: Rates of GDMT for HFrEF before primary prevention ICD implantation were low, and failure to achieve GDMT was associated with significantly decreased 1-year survival.

Keywords: defibrillator; health services research; heart failure.

Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Figures

Central Illustration. Medications before defibrillator implantation: Number of U.S. Hospital Referral Regions

Figure 1. Use of Guideline-Directed Medical Therapy for Heart Failure Prior to ICD Implant for 133 Hospital Referral Regions

This shows the proportion of patients with HFrEF receiving GDMT prior to implant of a primary prevention ICD for 133 Hospital Referral Regions (HRR) in the United States. Included were HRR in which > 50 ICD were implanted during study sample years 2007-2011. HFrEF = Heart failure with reduced ejection fraction; ICD = Implantable cardioverter-defibrillator