J Korean Med Sci.  2021 Oct;36(40):e252. 10.3346/jkms.2021.36.e252.

Evaluation of Adherence to Guideline for Heart Failure with Reduced Ejection Fraction in Heart Failure with Preserved Ejection Fraction and with or without Atrial Fibrillation

• Ahn MS
• Yoo BS
• Son JW
• Park YJ
• Lee HY
• Jeon ES
• Kang SM
• Choi DJ
• Kim KH
• Cho MC
• Kim SY
• Kang DR
• Go TH

• KMID: 2521425
• DOI: http://doi.org/10.3346/jkms.2021.36.e252

Abstract

Background
This study evaluated the relationship between guideline adherence for heart failure (HF) with reduced ejection fraction (HFrEF) at discharge and relevant clinical outcomes in patients with acute HF with preserved ejection fraction (HFpEF) with or without atrial fibrillation (AF).
Methods
We analyzed Korean Acute Heart Failure Registry data for 707 patients with HFpEF with documented AF and 687 without AF. Guideline adherence was defined as good or poor according to the prescription of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, and mineralocorticoid receptor antagonists. Anticoagulation adherence was also incorporated for the AF group.
Results
Among patients with normal sinus rhythm, those with poor guideline adherence had a reduced prevalence of comorbidities and favorable clinical characteristics when compared with those with good guideline adherence. Using inverse probability of treatment weighting (IPTW) to address the bias of nonrandom treatment assignment, good adherence was associated with a poor 60-day composite endpoint in the multivariable Cox model (weighted hazard ratio [wHR], 1.74; 95% confidence interval [CI], 1.01–3.00; P = 0.045). For patients with AF, baseline clinical characteristics were similar according to the degree of adherence. The IPTW-adjusted analysis indicated that good adherence was significantly associated with the 60-day composite endpoint (wHR, 0.47; 95% CI, 0.27–0.79; P = 0.005). In the analysis excluding warfarin, good adherence was associated with 60-day rehospitalization (wHR, 0.60; 95% CI, 0.37–0.98; P = 0.040), 1-year re-hospitalization (wHR, 0.67; 95% CI, 0.48–0.93; P = 0.018), and the composite endpoint (wHR, 0.77; 95% CI, 0.59–0.99; P = 0.041).
Conclusion
Our findings indicate that good adherence to guidelines for HFrEF is associated with a better 60-day composite endpoint in patients with HFpEF with AF.

Keyword

Heart Failure; Atrial Fibrillation; Guideline Adherence

Figure

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  Fig. 1 Inverse probability of treatment weighting-adjusted multivariate Cox regression forest plot of clinical outcomes in patients without atrial fibrillation with good guideline adherence versus those with poor guideline adherence.HFpEF = heart failure with preserved ejection fraction, HR = hazard ratio, CI = confidence interval.

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  Fig. 2 Inverse probability of treatment weighting-adjusted multivariate Cox regression forest plot of clinical outcomes in patients with atrial fibrillation with good guideline adherence versus those with poor guideline adherence.HFpEF = heart failure with preserved ejection fraction, AF = atrial fibrillation, HR = hazard ratio, CI = confidence interval.

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  Fig. 3 Inverse probability of treatment weighting-adjusted multivariate Cox regression forest plot of clinical outcomes in patients with good guideline adherence versus those with poor guideline adherence when warfarin was excluded.HFpEF = heart failure with preserved ejection fraction, AF = atrial fibrillation, HR = hazard ratio, CI = confidence interval.

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