Non-introduction or withdrawal of prognostic-modifying drugs in HF with reduced ejection fraction
Authors: Maciel C M , Martins F M 
Published: July 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Introduction
HF-FER has pharmacological strategies that allow better outcomes for patients, but the introduction of prognostic-modifying drugs or maximum dose titration is conditioned by the patient's performance, adverse effects, comorbidities and therapeutic inertia from physicians.

Objective
To evaluate the profile of patients admitted with a diagnosis of HF-FER in the Internal Medicine (IM) ward in 2019.

Methods
Retrospective analysis of hospitalized patients with HF-FER, evaluating the use of prognostic-modifying drugs, and adverse effects of drugs identified throughout the disease.

Results
We evaluated 130 patients (203 episodes) in 2019 with a diagnosis of HF-FER. 65.3% of patients (n:85) were on ACE inhibitors or ARBs. In 15.2% (n:13) the drug was introduced in 2019 and in 32.9% (n:28) the maximum dose of the drug was prescribed. We identified 30 patients (23%) with class withdrawal: 5 cases due to hypotension; 4 cases for renal dysfunction, 1 case for terminal HF and 20 cases not specified. In 19 patients (22%) on ACE inhibitors/ARBs, sacubitril/valsartan was introduced. As for beta-blockers, 81.5% of patients (n:106) had a prescription and in 20.7% of cases (n:22) the drug was initiated in 2019. This class was suspended in 9.2% of patients (n:22), with 5 cases for bradycardia, 2 cases for terminal HF and in 15 cases for unspecified reasons. As for the most recent prognostic modifying drugs, 17.7% of patients were on sacubitril/valsartan (n:23) with 86.9% (n:20) of patients starting it in 2019. The same was suspended in 7 patients : 2 cases for hypotension, 1 for hyperkalemia, 1 for renal dysfunction, 1 for economic insufficiency and in 2 cases not described. 17 patients (13.1%) were under iSGLT2, in which 88.2% of cases were introduced in 2019, with no drug suspension.
In cases where drugs were suspended, they were not reintroduced.
Among elderly patients (&gt;65 years), we identified 112 patients (179 episodes) with 51.7% (n:58) aged 85 years or older. 50% of patients in class III (n:56) and 40.2% in class IV (n:45) of the NYHA. 89.2% of the patients they remained oriented at the time of hospital discharge (n:100) or in the 2 days prior to the fatal event and 96% (n:108) of the patients maintained the ability to verbally express related symptoms. 66.9% of patients (n:75) were on ACE inhibitors or ARBs; 80.3% (n:90) under beta blocker; 30.3% (n:34) under aldosterone receptor inhibitor; 13.3% (n:15) under iSGLT2; 17.8% (n:20) under sacubitril-valsartan.

Conclusion
The impact of prognostic-modifying drugs on HF-FER should lead physicians to reflect on reasons for their suspension or non-introduction, emphasizing the importance of keeping in clinical records the limitations for their use. Withdrawal of drugs should prompt management of the identified adverse effect so that it can be reintroduced as soon as possible. Therapeutic inertia should be avoided, especially in individuals who may benefit from these drugs in the evolution of HF.