2026 Eastern States Conference

Title: Implementation gap in mineralocorticoid receptor antagonist use in patients with heart failure with reduced ejection fraction
Authors: Oyinlola Shofolawe-Bakare, PharmD; Scott Baker, PharmD, BCPS.
Learning objective: Audience members will be able to identify reasons for non-initiation of mineralocorticoid receptor antagonist in eligible heart failure patients with reduced ejection fraction and assess whether reasons are appropriate or if interventions could have been made to prevent non-initiation.
Self-assessment question: Which of the following non-initiation reasons can an intervention be potentially made to allow for initiation of MRA on discharge without the need for continuous monitoring?
 A.) Acute kidney injury
 B.) Acute hyperkalemia
 C.) Low blood pressure
 D.) None of these
Background: The objective of the study was to review hospitalized patients with heart failure with reduced ejection fraction (HFrEF) to identify reasons for non-initiation of mineralocorticoid receptor antagonists (MRAs) at hospital discharge and evaluate readmission rates within this group. The American college of cardiology/ American heart association guidelines recommend MRAs for optimized guideline directed medical therapy (GDMT) in patients with chronic HFrEF who remain symptomatic despite optimal dosing of (renin-angiotensin-aldosterone) RAAS inhibitors, beta blockers and other standard therapies. However, their use remains suboptimal in this demographic.
Methods: A single-center retrospective cohort study in adults with a HFrEF diagnosis and LVEF < 40% who at the time of discharge were eligible to receive an MRA but either received or did not receive an MRA on discharge. The primary outcome was 30-day heart failure readmission rates between patients who were not discharged on an MRA based on the reasons for non-initiation. Secondary outcomes included 30-day and 90-day hospital readmission rates among patients discharged with vs. without an MRA and 1-year mortality.
Results: Of 278 patients screened, 218 met the eligibility criteria for the study. 121 patients received and continued MRA on discharge. 97 patients did not receive MRA on discharge. Non-initiation on discharge was determined by the physician. The reasons for non-initiation were largely undocumented for most patients. Other reasons included blood pressure, renal function, hyperkalemia or the patients were deferred to outpatient cardiology for follow-up. Hospital readmission rates in these groups were 13.0%, 11.8%, 33.3%, 0.0% and 14.3% respectively. There was no statistically significant difference in 30-day re-admission rates among the groups. For secondary outcomes, there was a statistically significant difference in 30-day (2.4% vs 19%) and 90-day (5.7% vs. 21%) hospital readmission rates among patients discharged with vs. without an MRA (p-value < 0.001). However, there was no difference in 1-year mortality in both groups (p-value = 0.50).
Conclusion: In this small, retrospective cohort study, majority of patients who were eligible for an MRA received one on discharge. In the group of patients who did not receive an MRA, reasons fell into a few categories. Although there was no difference in 30-day readmission rates within the non-MRA initiation group, this study highlights the importance of evaluating the appropriateness of non-initiation of therapy.