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Racial Differences in Trends and Prognosis of Guideline-Directed Medical Therapy for Heart Failure with Reduced Ejection Fraction: the Atherosclerosis Risk in Communities (ARIC) Surveillance Study

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Abstract

Background

Racial disparities in guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) have not been fully documented in a community setting.

Methods

In the ARIC Surveillance Study (2005–2014), we examined racial differences in GDMT at discharge, its temporal trends, and the prognostic impact among individuals with hospitalized HFrEF, using weighted regression models to account for sampling design. Optimal GDMT was defined as beta blockers (BB), mineralocorticoid receptor antagonist (MRA) and ACE inhibitors (ACEI) or angiotensin II receptor blockers (ARB). Acceptable GDMT included either one of BB, MRA, ACEI/ARB or hydralazine plus nitrates (H-N).

Results

Of 16,455 (unweighted n = 3,669) HFrEF cases, 47% were Black. Only ~ 10% were discharged with optimal GDMT with higher proportion in Black than White individuals (11.1% vs. 8.6%, p < 0.001). BB use was > 80% in both racial groups while Black individuals were more likely to receive ACEI/ARB (62.0% vs. 54.6%) and MRA (18.0% vs. 13.8%) than Whites, with a similar pattern for H-N (21.8% vs. 10.1%). There was a trend of decreasing use of optimal GDMT in both groups, with significant decline of ACEI/ARB use in Whites (− 2.8% p < 0.01) but increasing H-N use in both groups (+ 6.5% and + 9.2%, p < 0.01). Only ACEI/ARB and BB were associated with lower 1-year mortality.

Conclusions

Optimal GDMT was prescribed in only ~ 10% of HFrEF patients at discharge but was more so in Black than White individuals. ACEI/ARB use declined in Whites while H-N use increased in both races. GDMT utilization, particularly ACEI/ARB, should be improved in Black and Whites individuals with HFrEF.

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Data availability

ARIC data is available through the NHLBI BioLINCC (https://biolincc.nhlbi.nih.gov/home/) or the ARIC Data Coordinating Center at the University of North Carolina (details can be found at https://sites.cscc.unc.edu/aric/distribution-agreements).

Code Availability

Custom code is available upon request.

Abbreviations

ACEI:

Angiotensin-converting-enzyme inhibitor

AF:

Atrial fibrillation or flutter

ARB:

Angiotensin-receptor blocker

ARIC:

Atherosclerosis Risk in Communities Study

BB:

Beta blocker

BMI:

Body mass index

CHD:

Coronary heart disease

CKD:

Chronic kidney disease

HF:

Heart failure

HFrEF:

Heart failure with reduced ejection fraction

H-N:

Hydralazine nitrate

HR:

Heart rate

GDMT:

Guideline-directed medical therapy

MMCC:

Morbidity and mortality

MRA:

Mineralocorticoid receptor antagonist

LVEF:

Left ventricular ejection fraction

SBP:

Systolic blood pressure

IABP:

Intra-aortic balloon pump

LVAD:

Left ventricular assist device

eGFR:

Estimated glomerular filtration rate

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Acknowledgements

The Atherosclerosis Risk in Communities study has been funded in whole or in part with Federal funds from the National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, under Contract nos. (HHSN268201700001I, HHSN268201700002I, HHSN268201700003I, HHSN268201700005I, HHSN268201700004I). The authors thank the staff and participants of the ARIC study for their important contributions.

Funding

Dr. Mathews was supported by Diversity Supplement under ARIC Contract Grant Number Contract HHSN268201700002I/ 75N92019F00074- from the National Heart, Lung, and Blood Institute, National Institutes of Health. Dr. Punjabi was supported by National Institute of Health Grant no. HL146709.

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Authors and Affiliations

  1. Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, 600 North Wolfe Street Blalock 524D, Baltimore, MD, 21287, USA

    Lena Mathews, Chiadi E. Ndumele & Kunihiro Matsushita

  2. Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Lena Mathews, Ning Ding, Yingying Sang, Jung-Im Shin, Naresh M. Punjabi, Deidra C. Crews, Josef Coresh, Chiadi E. Ndumele & Kunihiro Matsushita

  3. Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Laura R. Loehr, Wayne D. Rosamond & Patricia P. Chang

  4. Division of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Naresh M. Punjabi

  5. Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, NC, USA

    Alain G. Bertoni

  6. Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Deidra C. Crews

  7. Johns Hopkins Center for Health Equity, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Deidra C. Crews & Chiadi E. Ndumele

  8. Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Patricia P. Chang

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  1. Lena Mathews
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  2. Ning Ding
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  3. Yingying Sang
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Contributions

Lena Mathews: conceptualization, methodology, formal analysis, writing—original draft; Ning Ding: formal analysis; Yingying Sang: formal analysis; Laura R. Loehr: conceptualization, methodology; Jung-Im Shin: conceptualization, methodology; Naresh M. Punjabi: conceptualization, methodology; Alain G. Bertoni: conceptualization, methodology; Deidra C. Crews: conceptualization, methodology; Wayne D. Rosamond: conceptualization, methodology; Josef Coresh: conceptualization, methodology; Chiadi E. Ndumele: conceptualization, methodology, writing—original draft, supervision; Kunihiro Matsushita: conceptualization, methodology, writing—original draft, supervision; Patricia P. Chang: conceptualization, methodology, writing—original draft, supervision.

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Correspondence to Lena Mathews.

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This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Participating Institutions.

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Mathews, L., Ding, N., Sang, Y. et al. Racial Differences in Trends and Prognosis of Guideline-Directed Medical Therapy for Heart Failure with Reduced Ejection Fraction: the Atherosclerosis Risk in Communities (ARIC) Surveillance Study. J. Racial and Ethnic Health Disparities 10, 118–129 (2023). https://doi.org/10.1007/s40615-021-01202-5

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