Objective:
Current guidelines recommend use of combination therapy with angiotensin receptor blocker and neprilysin inhibitor (ARNI) (i.e., Entresto
®
) in patients with heart failure (HF) with reduced ejection fraction as a class 1 recommendation. Contemporary data on real-world use of these agents is lacking.
Methods:
This is a retrospective cohort study of individuals enrolled in Clinformatics® Data Mart Database (OptumInsight, Eden Prairie, MN from January 1, 2016 to December 31, 2018. We included all individuals ≥ 18 years, with two outpatient encounters or one inpatient encounter with a principal ICD 10 diagnosis for HFand 6 months of continuous enrollment. To further identify patients with reduced ejection fraction, we only included individuals who received prescriptions for beta-blockers and angiotensin converting enzyme inhibitors/ angiotensin receptor blockers. Comorbidities were identified using Elixhauser comorbidity index.. Multivariate logistic regression model was used to identify predictors of ARNI use.
Results:
A total of 154,777 patients were included in our cohort. Overall, 5,834 patients (3.8%) received an ARNI prescription. Use of ARNI increased from 1.4% in 2016 to 3.9% in 2018 (p<0.01). Compared to patients receiving angiotensin converting enzyme inhibitors/angiotensin receptor blockers, patients receiving ARNI were younger (mean age 69.4 ± 11.1 vs. 72.9 ± 11.0 years;), more likely to be male (69.3% vs. 54.4%) and have commercial insurance (22.1% vs. 16.7%) with a higher comorbidity burden. Predictors of ARNI use after multivariable adjustment included age<65 years (OR 1.4; 95% CI 1.3-1.5), Male sex (OR 1.8; 95% CI 1.7 - 1.9) and black race (OR 1.2; 95% CI 1.1 - 1.2). Other predictors of ARNI use are shown in Figure 1. Patients receiving care through a cardiologist compared to a primary care physician were more likely to receive an ARNI (OR 1.8; 95% 1.7 - 1.9). Out of pocket cost for ARNI ranged from $0 to $1006 per month (median $44; IQR $9-$60).
Conclusion:
Rates of ARNI use remain low among patients with heart failure with racial and gender disparities. Heart Failure patients receiving care with a cardiologist were more likely to receive ARNI. Out of pocket cost for this medication remains high and may be a significant barrier to its use.
Rationale for and Practical Use of Sacubitril/Valsartan in the Patient’s Journey with Heart Failure and Reduced Ejection Fraction
