Suboptimal guideline-directed medical therapy and prognosis in patients with heart failure and reduced ejection fraction: The SMYRNA Study

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Abstract Background Heart failure and reduced ejection fraction (HFrEF) is associated with an increased risk of morbidity and mortality. Despite strong evidence from the randomized-controlled trials and recommendations of guidelines, the use of guideline-directed medical therapy (GDMT) among patients with HFrEF remains suboptimal in a real-life setting. Purpose The Suboptimal guideline-directed Medical therapY and prognosis in patients with heaRt failure and reduced ejectioN frAction (SMYRNA) study aims to determine the prognostic significance of GDMT in patients with HFrEF. Methods The SMYRNA study is a prospective, multicenter, and observational study that included outpatients with HFrEF. The study population enrolled at 41 cardiology centers between January 2019 and June 2019. Patients were divided into 3 groups: those treated with ≤1 class of HF medication, 2 classes of HF medications, and 3 classes of HF medications. The primary outcome was a composite of cardiovascular death or hospitalization for heart failure, analyzed as the time to the first event. Results The study population consisted of 1,062 patients with HFrEF, predominantly men (69.1%), with a median age of 68 (20–96) years. RAS inhibitors, beta-blockers, and MRAs were prescribed in 76.0%, 89.4%, and 55.1%, of the patients at the time of study enrollment, respectively. The proportions of patients receiving target doses of medications were 24.4% for RAS inhibitors, 11.0% for beta-blockers, and 11.1% for MRAs (Figure 1). The median follow-up was 24 months. The rate of primary composite outcome was 40.4% among patients treated with ≤1 class of HF medication, 32.0% among patients treated with 2 classes of HF medications, and 32.8% among patients treated with 3 classes of HF medications. Patients treated with 2 or 3 classes of HF medications had a decreased risk of cardiovascular death or hospitalization for heart failure compared to those patients receiving ≤1 class of HF medication (HR, 0.65; 95% CI, 0.49 to 0.85; P = 0.002, and HR, 0.61; 95% CI, 0.47 to 0.79; P<0.001, respectively, Figure 2). Conclusion The real-life SMYRNA study showed that suboptimal GDMT is strongly associated with an increased risk of cardiovascular death or hospitalization for heart failure in patients with HFrEF.Figure 1Figure 2

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