OBJECTIVES:

Half of patients with heart failure have preserved ejection fraction (HFpEF). Over the years, guidelines have recommended (e.g., angiotensin receptor blockers (ARBs)) or advised against (e.g., nitrates) various therapies for HFpEF management. However, there is limited evidence on the trends in utilization of HFpEF medications. We examined the trends in use of pharmacotherapies among patients with HFpEF from 2008 through 2020.

METHODS:

We conducted a cohort study of patients with HFpEF using MarketScan^® Commercial and Medicare Supplemental Databases (2007-2020). Patients were identified using International Classification of Diseases, Ninth or Tenth Revision, Clinical Modification diagnosis codes for HFpEF. We estimated annual utilization rates for angiotensin-converting enzyme inhibitors (ACEIs), ARBs, angiotensin receptor-neprilysin inhibitors (ARNIs), aldosterone receptor antagonists (ARAs), diuretics, β-blockers, calcium channel blockers (CCBs), phosphodiesterase 5 inhibitors (PDE5Is), nitrates, and digoxin within 90 days of the first HFpEF diagnosis. Multivariable Poisson regression models were used to estimate adjusted utilization trends during the study period.

RESULTS:

We identified 156,730 patients with HFpEF (mean [SD] age, 73 [13.4] years; 57% females). From 2008 to 2020, we found increased utilization rates for ARNIs (0.02% vs. 0.17% of all patients, p<0.01), ARBs (14.3% vs. 18.6%, p<0.01), ARAs (7.0% vs. 8.4%, p<0.01), and CCBs (30.6% vs. 33.4%, p<0.01). By contrast, the utilization of ACEIs (30.4% vs. 20.5%, p<0.01), digoxin (9.5% vs. 2.4%, p<0.01), nitrates (10.7% vs. 4.9%, p<0.01), diuretics (54.1% vs. 50.4%, p=0.20), and β-blockers (52.6% vs. 51.7%, p<0.01) decreased, while utilization rates of PDE5Is remained stable (1.5% vs. 1.1%, p=0.90).

CONCLUSIONS:

During the 13-year study period, the utilization of ARNIs, ARBs, ARAs, and CCBs increased while the utilization of digoxin, nitrates, diuretics, and β-blockers decreased among patients with HFpEF. Large scale studies are warranted to determine safety of CCBs in HFpEF because these negative inotropes may exacerbate heart failure.