Intensity of guideline-directed medical therapy for coronary heart disease and ischemic heart failure outcomes

Aims — The impact of guideline-directed medical therapy for coronary heart disease in those with hospitalized acute heart failure is unknown.

Methods — We studied guideline-directed medical therapies for coronary disease: ACE inhibitors or ARBs, beta-adrenoreceptor antagonists, antiplatelet agents and/or anticoagulants, and statins. Using inverse probability of treatment weighting using the propensity score, we examined associations of guideline-directed medical therapy intensity (categorized as low [0-1], high [2-3], or very high [4] number of drugs) with mortality in 1873 patients with angina, troponin elevation or prior myocardial infarction.

Results — At discharge, 0-1, 2-3, and 4 medications were prescribed in 467 (25%), 705 (38%), and 701 (37%), respectively. Relative to those prescribed 0-1 drugs (reference), all-cause mortality was lower with 2-3 (hazards ratio [HR] 0.48; 95%CI; 0.28-0.84, p=0.009) or all 4 drug classes (HR 0.56; 95%CI; 0.33-0.96, p=0.034) over 181-365 days, with similar reductions present from 0-180 days. In those with heart failure with preserved ejection fraction, mortality trended lower with 2-3 drug classes (HR 0.43; 95%CI; 0.18-1.02, p=0.054) and was significantly reduced with 4 drugs (HR 0.32; 95%CI; 0.12-0.84, p=0.021) during 0-180 day follow-up. In heart failure with reduced ejection fraction, all-cause mortality was reduced during both 0-180 and 181-365 day periods when discharged on 2-3 (HR 0.30 for 181-365 days; 95%CI; 0.14-0.64, p=0.002) or all 4 drug classes (HR 0.43; 95%CI; 0.19-0.95, p=0.038).

Conclusions — Increasing guideline-directed medical therapy intensity for coronary heart disease resulted in lower mortality in patients with acute ischemic heart failure with both preserved and reduced ejection fractions.