Use of and Association between Heart Failure Pharmacological Treatments and Outcomes in Obese vs. non-Obese Patients with Heart Failure with Reduced Ejection Fraction: Data from the Swedish Heart Failure Registry

Aims: To investigate the use of guideline directed medical therapies (GDMT) and associated outcomes in obese (body mass index, BMI≥30 kg/m2) vs. non-obese patients with heart failure with reduced ejection fraction (HFrEF). Methods and results: HFrEF patients from the Swedish HF Registry were included. Of 16 116 patients, 24% were obese. In obese vs. non-obese patients, use of treatments was 91% vs. 86% for renin-angiotensin-system-inhibitors (RASi)/angiotensin-renin-neprilysin-inhibitors (ARNi), 94% vs. 91% for beta-blockers, 53% vs. 43% for mineralocorticoid-receptor-antagonists (MRA). Obesity was shown to be independently associated with more likely use of each treatment, triple combination therapy, and the achievement of target dose (TD) by multivariable logistic regressions. Multivariable Cox regressions showed use of RASi/ARNi and of beta-blockers being independently associated with lower risk of all-cause/cardiovascular death (CVD) regardless of obesity, although, when considering competing risks, a lower risk of CVD with RASi/ARNi in obese vs. non-obese patients was observed. RASi/ARNi were associated with lower risk of HF hospitalization in obese but not in non-obese patients, whereas beta-blockers were not associated with the risk of HF hospitalization regardless of obesity. At the competing risk analysis, RASi/ARNi use was associated with higher risk of HF hospitalization regardless of obesity. Conclusion: Obese patients were more likely to receive optimal treatments after adjustment for factors affecting tolerability, suggesting that perceived beyond actual tolerance issues limits GDMT implementation. RASi/ARNi and beta-blockers were associated with lower mortality regardless of obesity, with a greater association between RASi/ARNi and lower CVD in obese vs. non-obese patients when considering competing risk.