Medical treatments at 6 months in hospitalized and ambulatory HFrEF patients in the BRING-UP 3 Heart Failure study

Aims: The BRING-UP 3 Heart Failure (HF) study was designed to the real-world implementation of guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF), given the limited evidence on the uptake of the contemporary four-pillar treatment strategy. Methods: BRING-UP 3 HF study is an observational, prospective, nationwide investigation encompassing 179 sites. This analysis includes HFrEF patients enrolled in the ambulatory and hospitalized cohorts with complete pharmacological data at 6-month follow-up. The objective was to describe the use of the four GDMT pillars after 6 months. Results: Among 3,201 HFrEF patients enrolled, 142 (4.4%) had died by 6 months, and treatment data were available for 2950 patients. Mean age was 69±11 years (26.6% >75 years), 18.0% were female. Prescription rates of GDMT were high at baseline and remained stable over 6-months, with a shift from ACE-I/ARBs to ARNIs, and a modest increase in SGLT2i use. A significant reduction in diuretic prescription was also observed. Quadruple therapy was prescribed in 64.3% of patients at 6 months versus 63.9% at baseline/discharge (p=NS), while quadruple therapy including ARNI went from 52.9% to 55.9%, p <0.0001. Dose up-titration of GDMT remained suboptimal, with most agents prescribed at <50% of target doses. Discontinuation rates at follow-up were very low. Conclusions: In this large nationwide cohort, guideline-directed therapies for HFrEF were widely implemented and maintained over 6 months with excellent treatment persistence. However, dose optimization remains a key unmet need in routine clinical practice.