Longitudinal Titration of Medical Therapy for Heart Failure with Reduced Ejection Fraction: CHAMP-HF Registry

Abstract Background Guidelines recommend titration of medical therapy for heart failure with reduced ejection fraction (HFrEF) to target doses derived from clinical trials. The degree to which titration occurs in contemporary United States (U.S.) practice is unknown. Objectives We sought to characterize longitudinal titration of HFrEF medical therapy in clinical practice and identify associated factors and reasons for medication changes. Methods Among 2,588 U.S. outpatients with chronic HFrEF in the CHAMP-HF registry with complete medication data and no contraindications to medical therapy, use and dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor neprilysin inhibitor (ARNI), beta-blocker, and mineralocorticoid receptor antagonist (MRA) were examined at baseline and 12-month follow-up. Results At baseline, 658, 525, 287, and 45 patients were receiving target doses of MRA, beta-blocker, ACEI/ARB, and ARNI, respectively. At 12-months, proportions of patients with medication initiation/dosing increase were 6% for MRA, 10% for beta-blocker, 7% for ACEI/ARB, and 10% for ARNI; corresponding proportions with discontinuation/dosing decrease were 4%, 7%, 11%, and 3%. Over 12 months, Conclusions In this contemporary U.S. registry, the large majority of eligible HFrEF patients did not receive target doses of medical therapy at any point during follow-up and few patients had doses increased over time. Although most patients had no alterations in medical therapy, multiple clinical factors were independently associated with medication changes. Further quality improvement efforts are urgently needed to improve guideline-directed medication titration.