Real world data on adopting guideline directed medical therapy post 2021 ESC HF guidelines and effect on renal function
Authors: Ferrari M , Macken E , Virxinia S , Heres P , Jouhara S , Mandarano L , Ray R , Shanmugam N , Anderson L , Banerjee D , Rosano G , Maggi A , Di Meo P A , Metra M , Jouhra F 
Published: November 2023

Abstract

Introduction
This single-centre cohort study aims to compare the use of guideline-directed medical therapies (GDMT) before and after the 2021 ESC HF guidelines and the effect on renal function. There has been good adoption of these guidelines worldwide following the publication in 2021. We know HF patients will have less decline in renal function when GDMT is better optimised. This study aims to compare renal function on admission (adm) and discharge (dc) following acute heart failure admission.

Methods
Our database is composed of 460 patients with AHF admitted to our HF unit from 01/08/2020 till 31/07/2022inclusive. We divided this group into two; Group A was composed of 187 patients from August 2020 to Aug 2021(pre-ESC guidelines) and Group B included 273 patients from August 2021 to Aug 2022 (post-ESC guidelines). We compared the number of patients initiated on the 4 pillars of HF medication on admission and discharge. Both groups were analysed based on their ejection fraction (HFrEF, HFmrEF and HFpEF). Baseline parameters were were similar between the two groups. We analyzed eGFR (mL/min) on admission (adm), eGFR on discharge (dc), K+ (mmol/l) on dc and the 8 medications for HFrEF and HFmrEF. We also reviewed three medications for HFpEF.

Results
Group A (Aug 2020-Aug 2021): HFrEF patients had an average eGFR of 52.4 on adm and 47,0 at dc, average K+ was 4.34 on dc. HFmrEF subgroup had an average eGFR of 48.8 on adm and 45.4 at dc, average K+ was 4.23 on dc. HFpEF subgroup had an average eGFR of 51.2 on adm and 44.2 at dc, average K+ was 4.24 on dc.
Group B (Aug 2021-Aug 2022): HFrEF patients had an average eGFR of 53.5 on adm and 50.7 dc, average K+ was 4.38 on dc. HFmrEF subgroup had an average eGFR of 49.4 on adm and 47.0 at dc, average K+ was 4.34 on dc. HFpEF subgroup had an average eGFR of 45.9 on adm and 41.7 at dc, average K+ was 4.35 on dc.
Group A and B comparison (Table1): In Group A, HFrEF patients had a drop of eGFR of 5.4 between adm and dc. However, HFrEF patients in Group B, where they had their GDMT optimized, had an eGFR drop of only 2.8 (less by 2.6). In Group A, HFmrEF patients had an eGFR drop of 3.4 in comparison to HFmrEF patients in Group B where eGFR dropped by 2.4 (less by 1.0). In Group A, HFpEF subgroup had an eGFR drop of 7.0 versus Group B HFpEF where eGFR dropped by 4.2 only (less by 2.8). Despite better GDMT in group B, K+ was comparable to group A.

Conclusions
Patients with AHF managed in the HF Unit have better optimization of GDMT post 2021 HF ESC guidelines. In Group B, all patient subgroups (HFrEF; HFmrEF and HFpEF) in the year following publication of the ESC HF guidelines had a reduced decline in eGFR i.e. less worsening of renal function despite higher dose and a greater percentage of patients on the 4 pillars of GDMT. This study demonstrates that renal function of patients admitted with AHF is better preserved with optimization of GMDT during their admission.MEDICATIONS (GDMT)RENAL FUNCTION