Abstract 64: Cardiac Rehabilitation: A Missed Opportunity For Heart Failure Medication Optimization?

Background: Guideline-directed medical therapy (GDMT) reduces hospitalization and death in heart failure with reduced ejection fraction (HFrEF), but GDMT is often not fully optimized. Cardiac rehabilitation, with frequent in-person assessment, may provide an unrealized opportunity to optimize GDMT.

Methods: We analyzed the Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION) study, which showed cardiac rehabilitation in stable HFrEF was safe and improved functional status. We applied a previously validated GDMT optimization algorithm to the baseline HF-ACTION data. It uses medications/doses, vitals, and labs to calculate a medication optimization score (MOS: range 0-100%; 100% is fully optimized for clinical status). We hypothesized the MOS would identify GDMT titration opportunities and predict clinical outcomes.

Results: Of 2130 patients, 27% (n=578) had MOS 100%; GDMT barriers (e.g. low blood pressure, renal dysfunction) were more common in this group. Among 1552 non-optimized patients (age 58±13, 28% female, 39% non-White, ejection fraction 25±7%) the median MOS was 50% (IQR 38-60%) (Figure 1). After adjustment using the HF-ACTION risk model, higher MOS was associated with a decrease in death or all-cause hospitalization (HR 0.66, 95% CI 0.48-0.90, p=0.009); for each 10% MOS increase (example: metoprolol increase from 100 to 200 mg daily) the composite endpoint decreased 4.1%. Figure 2 shows survival curves for an MOS of 25%, 50% and 75%.

Conclusion: Among patients with HFrEF undergoing cardiac rehabilitation, the MOS outlines ample opportunity for GDMT titration and predicts clinical outcomes in non-optimized patients