Heart failure, frailty & guideline-directed medical therapy

Guideline-directed medical therapy (GDMT) is recommended as a clinical guideline for patients suffering from heart failure with reduced ejection fraction, also known as HFrEF. This therapy includes treatments such as beta-blockers, mineralocorticoid receptor antagonists (MRAs), ARNI and SGLT2 inhibitors (to be used unless they are not tolerated by the patient). However, not all elderly patients receive full GDMT. Certain drugs may not be possible to prescribe to elderly patients, such as RAS inhibitors, due to the patients experiencing hypotension, but there are GDMT alternatives, such as MRAs. Yet, those not receving GDMT experience issues such as renal impairment, lower heart rate and hyperkalaemia.

Analysis of the characteristics of patients not receiving GDMT revealed that physical frailty is often associated with a lack of GDMT prescription at hospital discharge.
This review by Hamada T et al. aimed to understand why, although recommended to clinicians, guideline-directed medical therapy is not always prescribed to elderly patients suffering from heart failure.

Key learnings:

Overall, GDMT has not been implemented properly in elderly patients in clinical practice. However, it has also not been sufficiently researched, as it is not known whether GDMT can reduce adverse outcomes in patients who are more frail and physically vulnerable. Tolerability needs to continue to be explored among vulnerable patients.