Clinical Application of Guideline-Directed Medical Therapy in TAVR Patients With Heart Failure and Reduced Ejection Fraction

Background There are limited data concerning the impact of heart failure (HF) guideline-directed medical therapy (GDMT) in patients with HF with reduced ejection fraction (HFrEF) who undergo transcatheter aortic valve replacement (TAVR). Objectives The aims of this study were to determine whether TAVR patients with HFrEF receive optimal HF-GDMT and to investigate the prognostic significance of HF-GDMT in this setting. Methods In a prospective registry, consecutive TAVR patients with HFrEF were stratified into 4 groups (quadruple, triple, double, or single or no therapy) according to prescription of HF-GDMT at discharge post-TAVR and after a 3-month GDMT optimization period. Major adverse cardiovascular events (MACE) were defined as a composite of cardiovascular mortality or hospitalization for heart failure. The median follow-up time was 699 days (Q1-Q3: 510-961 days). Results Among 336 TAVR patients with HFrEF, the rates of quadruple, triple, double, and single or no HF-GDMT were 15%, 19%, 28%, and 38% at discharge and 27%, 21%, 21%, and 27% at 3 months postprocedure, respectively. Among 280 patients (83.3%) eligible for quadruple HF-GDMT, only 27% (n = 76) received this combination at 3 months post-TAVR. Following a 3-month HF-GDMT optimization period, 2-year MACE rates were lower in patients taking quadruple (15.0%; 95% CI: 5.2%-24.8%) compared with triple (22.6%; 95% CI: 10.4%-34.8%), double (24.2%; 95% CI: 13.8%-34.6%), and single or no therapy (43.6%; 95% CI: 31.8%-55.4%; log-rank P < 0.001). Conclusions HF-GDMT is underused in patients with HFrEF who undergo TAVR, and suboptimal HF-GDMT is associated with increased MACE in this setting. Strategies to improve the initiation and up-titration of HF-GDMT in TAVR patients with HFrEF are needed.