title: Use of Guideline-Directed Medications for Heart Failure Before Cardioverter-Defibrillator Implantation.
abstract: BACKGROUND
  Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) is recommended before primary prevention implantable cardioverter-defibrillator (ICD) placement. Adherence to this recommendation and associated outcomes are unknown.
  
  
  OBJECTIVE
  This study examined the use of GDMT (≥1 prescription filled for both a renin-angiotensin inhibitor [RAI] and a heart failure-approved beta-blocker [HFBB]) within 90 days before primary prevention ICD placement in patients with HFrEF.
  
  
  METHODS
  Data from the National Cardiovascular Data Registry ICD Registry were merged with a 40% random sample of Medicare administrative data. Prescription fills for recipients of primary prevention ICD between 2007 and 2011 were examined, analyzing GDMT overall and for each U.S. hospital referral region. We identified characteristics associated with GDMT and the association with 1-year mortality.
  
  
  RESULTS
  Among 19,733 patients with HFrEF and primary prevention ICD, 61.1% filled any GDMT before implantation. Across hospital referral regions, GDMT was applied in 51% to 71%. The strongest predictors of any GDMT included absence of chronic renal disease or nonsustained ventricular tachycardia, low-income prescription benefits subsidy, and less recent left ventricular ejection fraction evaluation. Patients receiving GDMT versus those without had a lower 1-year mortality rate after ICD implantation (11.1% vs. 16.2%), even after adjustment for comorbidities, left ventricular ejection fraction, and functional heart failure class.
  
  
  CONCLUSIONS
  Rates of GDMT for HFrEF before primary prevention ICD implantation were low, and failure to achieve GDMT was associated with significantly decreased 1-year survival.
authors.affiliation: Division of Cardiology and Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington. Electronic address: rothg@uw.edu.
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Roth
authors.affiliation: Division of Cardiology, University of Washington, Seattle, Washington.
authors.forename: Jeanne E
authors.initials: JE
authors.lastname: Poole
authors.affiliation: The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Zaha
authors.affiliation: The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire.
authors.forename: Weiping
authors.initials: W
authors.lastname: Zhou
authors.affiliation: Department of Economics, Dartmouth College, and the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Skinner
authors.affiliation: The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire; Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
authors.forename: Nancy E
authors.initials: NE
authors.lastname: Morden
mesh_terms: D000368:Aged; D017147:Defibrillators, Implantable; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence; D006333:Heart Failure / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D008297:Male; D010349:Patient Compliance; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D016277:Ventricular Function, Left
keywords: defibrillator; health services research; heart failure