Impact of adherence to guideline‐directed therapy on risk of death in HF patients across an ejection fraction spectrum

AIMS: How different degrees of adherence to guideline‐directed medical therapy (GDMT) affect mortality risk in patients with heart failure (HF) in a real‐world clinical setting is poorly understood. This study sought to investigate how different levels of adherence to GDMT were associated with the risk of all‐cause mortality in patients with HF across a spectrum of left ventricular ejection fractions (LVEFs) in a real‐world clinical setting. METHODS AND RESULTS: A total of 64 610 HF patients with no missing value of LVEF from the Swedish Heart Failure Registry were included in the study. Patients were divided according to different LVEFs (<30%, 30–39%, 40–49%, and≥50%) and stratified by an adherence score (good, moderate, or poor) according to the triple, double, and single one usage of GDMT: angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers, beta‐blockers, and mineralocorticoid receptor antagonists. The outcome is time to all‐cause mortality. The mean age of the whole cohort was 73.9 ± 12.1 years, and the proportion of patients in LVEF < 30%, 30–39%, 40–49%, and≥50% groups was 27.6%, 26.9%, 22.1%, and 23.3%, respectively. Patients with LVEF < 30% had the highest mortality rate, almost 20% higher than those with LVEF ≥ 50% {hazard ratio [HR] [95% confidence interval (CI)]: 0.80 [0.71–0.90], P < 0.001}. After treatment of GDMT with good adherence, patients with LVEF < 30% had similar mortality to those with LVEF ≥ 50% [HR (95% CI): 0.97 (0.86–1.10), P = 0.664]. However, the percentage of moderate or poor GDMT was alarmingly high, with good adherence only in 20% of the patients. CONCLUSIONS: Good adherence to GDMT works best in patients with LVEF < 50%, whereas moderate adherence to GDMT varies in efficacy depending on the components of the drug combinations.