Background: There are limited treatment options for patients with HFpEF, with guidelines focusing on diuresis and management of associated cardiovascular conditions. In the TOPCAT trial, treatment with spironolactone in patients with HFpEF compared to placebo did not significantly decrease the incidence of the composite primary outcome, but the incidence of heart failure (HF) hospitalization was significantly lower. The impact of the TOPCAT results on mineralocorticoid antagonists (MRA) prescribing rates is unknown. We analyzed discharge prescribing rates of MRAs in the Get With The Guidelines-Heart Failure (GWTG-HF) registry to assess for practice changes following dissemination of TOPCAT results in 2013.
Methods: All patients recorded in GWTG-HF with LVEF ≥ 50% and discharged between January 2009 and December 2016 were included in the study. Data were summarized by calendar year quarters (Q). The TOPCAT trial results were first presented in November 2013, so patients were dichotomized into those discharged before TOPCAT (2009Q1 through 2013Q3) and those after TOPCAT (2013Q4 through 2016Q4). Discharge prescribing rates for MRAs, beta blockers, ACE inhibitors, and ARBs were assessed for overall trends and change in prescribing rates after 2013Q3 by segmented regression.
Results: Of 142,201 HFpEF patients included in the study, 18,581 (13.1%) were prescribed a MRA at discharge. Throughout the study period, MRA prescribing steadily increased (2009Q1 = 11.3%; 2016Q4 = 14.8%), without significant change in overall trend following announcement of TOPCAT results (p=0.17) (Figure 1). Discharge prescribing rates were largely stable for beta blockers but with a statistically significant change in trend after TOPCAT (2009Q1 = 82.8%; 2016Q4 = 80.5%; p < 0.0001), while prescribing rates for ACE/ARB decreased significantly throughout the study period without change in trend following TOPCAT (2009Q1 = 74.7%; 2016Q4 = 53.7%; p = 0.58).
Conclusions: The prescribing rates for MRAs in HFpEF at hospital discharge modestly increased over time, with little discernible influence of TOPCAT. These findings suggest there
has been gradual, modest MRA adoption in the absence of other therapeutic options and highlight the need for further trials on the efficacy and safety of MRAs in HFpEF.