2026 Southeastern Residency Conference

Optimization of Guideline-Directed Medical Therapy in Veterans Hospitalized with an Acute Heart Failure Exacerbation
Benjamin Brewer, Mary Martin McGill
Birmingham VA Health Care System-Birmingham, AL
Background/Purpose: Recent guidance for treatment of heart failure with reduced ejection fraction (HFrEF) states that patients with HFrEF should have guideline-directed medical therapy (GDMT) initiated and then titrated to maximum dose as quickly as possible . Previous studies have shown inpatient titration of GDMT is safe. The purpose of this study is to evaluate the difference in 30-day readmission rate in patients with HFrEF hospitalized with an acute heart failure exacerbation in patients who have GDMT optimized in order to obtain current real world data GDMT usage and evaluate how GDMT utilization at discharge effects patient outcomes.
Methodology: This will be a retrospective observational chart review conducted by reviewing medical records of patients hospitalized with an acute heart failure exacerbation between 3/15/2025 and 9/24/2025. Inclusion criteria will include admission for heart failure exacerbation and documented ejection fraction (EF) < 40%. Exclusion criteria will include patients discharge to palliative care or patients undergoing dialysis. Patients with more than two admissions will only have the first readmission counted. Readmissions were not counted if for non-HFrEF indication. GDMT is considered an angiotensin converting enzyme inhibitor (ACEi)/angiotensin II receptor blocker (ARB)/angiotensin receptor neprilysin inhibitor (ARNi), HF-specific beta blocker (BB), mineralocorticoid receptor antagonist (MRA) and sodium glucose cotransporter 2 inhibitor (SGLT2i) at maximum tolerated doses. Medication reconciliation on admission will be compared to the discharge medication list given to the patient. Patients will be grouped by whether GDMT medication was titrated or if therapy was not escalated.
Results: There were 140 patients reviewed and 65 met inclusion criteria. Of those 65 patients included in the study 32 had GDMT titrated at discharge and 33 did not have GDMT titrated at discharge.  Nine (28%) patients in the optimized group were readmitted within 30-days and 6 (18%) patients were readmitted from the non GDMT optimized group (Relative Risk: 1.40; p-value: 0.40). Patient population is underpowered for statistical significance, but increased readmission rates could indicate clinical significance. Of the patient’s who had GDMT titrated,  the most  commonly titrated medication group was SGLT2i. They were optimized in 14 (44.8%) patients, next were BB and ACEi/ARB/ARNi which was each optimized in 13 patients (40.6%), and the least commonly optimized group was MRAs. They were optimized in 7 (21.9%) of patients. In patients who had GDMT titrated 17 (53.1%) also had loop diuretics add or titrated on discharge compare to 13 (39%) in those who did not have GDMT titrated. The pharmacy cardiology clinic provided quicker post discharge follow-up at an average of five days post discharge and met with 52.3% within 30 days of discharge, compared to cardiology clinic (11 days; 18% of patients), and primary care (7 days; 10.8% of patients). Forty-three of the patients received follow-up from a cardiology pharmacist, cardiology, or primary care and of those patients 4 (9.3%) were readmitted compared to those who did not receive follow-up with 30 days 12out of 22 (54.5%) were readmitted.
Conclusions: There were a few limitations that limit the applicability of these results to the overall population. The study had a small sample size evaluated over a short time period, there are many confounding variables, and data was only collected form a single facility. Follow-ups are limited by failure to reach patient, readmission, and possible lack of established care within BVAHCS. From this data medication titration at discharge was not associated with an increase of 30-day readmission. However, the opportunity to further titrate GDMT upon discharge does exist, specifically in MRAs.
Presentation Objective: Evaluate 30-day readmission rates of HFrEF admissions who have GDMT titrated at discharge in the Birmingham VA Health Care System (BVAHCS).
Self-Assessment: Which of the following is not a first line option for optimizing GDMT?