Temporal changes in guideline-directed medical therapy score and clinical outcomes in patients with heart failure

AIMS: Optimisation of guideline-directed medical therapy (GDMT) is a cornerstone of management in heart failure (HF). The GDMT scoring system was developed to quantify both the use and intensification of GDMT. This study investigated the longitudinal changes in the GDMT score and its association with clinical outcomes in contemporary practice. METHODS AND RESULTS: This multicentre prospective cohort study included 680 patients with chronic HF with reduced ejection fraction. The patients were classified into the up-titration (n = 282) and no up-titration (n = 398) groups according to changes in the GDMT score over 9 months. The GDMT score incorporated the use and dose of guideline-recommended drugs including quadruple therapy, ivabradine, and vericiguat. The primary outcome was a composite of all-cause death and hospitalisation for worsening HF. Inverse probability of treatment weighting was used to adjust for baseline differences. Up-titration rates at 9 months were 31.8% for renin-angiotensin system blockers, 28.2% for β-blockers, 10.6% for mineralocorticoid receptor antagonists, and 11.9% for sodium-glucose cotransporter 2 inhibitors. Up-titration was independently associated with baseline GDMT score, age, left ventricular ejection fraction, blood pressure, and renal function. Furthermore, up-titration was associated with a lower incidence of the primary outcome than no up-titration (adjusted HR, 0.65; 95% CI, 0.43-0.98). CONCLUSION: In this contemporary chronic HF cohort, the GDMT score incorporating guideline-recommended drugs revealed suboptimal implementation and intensification of GDMT over 9 months. Greater increases in GDMT score were associated with improved clinical outcomes, supporting the clinical relevance of longitudinal GDMT optimisation.