Abstract 4373188: Optimal GDMT Use According to Frailty Status Following Diagnosis of HFrEF Among Medicare Fee for Service Beneficiaries

Background: Frailty and HF often co-exist identifying a population at increased risk for CV events. While perceived frailty may be a potential driver of clinical inertia, conventional HF therapy may reduce worsening HF and hospitalization which can lead to progressive frailty. Few contemporary data exist examining longitudinal patterns of GDMT use according to frailty status. Methods: In this retrospective nationwide cohort study, we identified 548, 841 patients with a new diagnosis of HFrEF in a 100% Medicare Fee for service sample with available data for Part D medication use between January 2016 to December 2023. Frailty was assessed using the Hospital Frailty Risk Score (HFRS) derived from ICD-10 codes and patients were categorized as low (HFRS<5), intermediate (HFRS 5-15) and high (HFRS>15) frailty risk. Optimal quadruple GDMT was defined as ≥ 50% of the target daily dose of beta blocker and ACEi/ARB or any dose of ARNI, MRA or SGLT2i. Time to optimal GDMT use according HFRS category was assessed using cumulative incidence curves. Results: Among 548, 841 patients with a new diagnosis of HFrEF, the mean age was 77 ± 11 years, 48% were women and the median HFRS was 77. 123,798(23%), 239,669 (44%) and 185,374 (34%) of patients were categorized as low, intermediate and high frailty risk, respectively. Compared to patients in the lowest frailty risk category, patients in the intermediate (HR 1.38; 95%CI: 1.35-1.41) and high risk(HR1.95; 95%CI: 1.90-2.00) categories experienced greater risk of mortality. The proportional use of optimal GDMT was lowest among patients with the highest levels of frailty at baseline (low: 7.7%; intermediate: 6.3%, high: 3.4%; P<0.0001) and remained suboptimal at 12 months (low: 11.9%; intermediate: 9.2%, high: 5.4%; P<0.0001); Figure 1 . Among patient not on optimal GDMT at baseline, patients with the highest frailty risk had a significantly lower probability of achieving optimal GDMT in follow up(P<0.001); Figure 1 . Achievement of optimal GDMT in follow up was associated with a substantially lower risk of subsequent 1 year mortality (HR 0.50; 95%CI: 0.47-0.52) independent of frailty burden (P<0.0001). Conclusion: In this nationwide cohort of newly diagnosed HFrEF, approximately 1 in 3 patients had high frailty risk. Such patients experienced worse outcomes and both the lowest proportional use and greatest time to optimal GDMT in follow up highlighting significant implementation gaps in this high-risk population.