Hospital Variability in the Use of Vasoactive Agents in Patients Hospitalized for Acute Decompensated Heart Failure: Clinical Phenotypes and Therapeutic Approaches

Background The absence of practice standards in vasoactive agent usage for acute decompensated heart failure (ADHF) has resulted in significant treatment variability across hospitals, potentially affecting patient outcomes. This study aimed to assess temporal trends and institutional differences in vasodilator and inotrope/vasopressor utilization among ADHF patients, considering their clinical phenotypes.

Data were extracted from a government-funded multicenter registry covering the Tokyo metropolitan area, comprising 44,444 consecutive patients urgently hospitalized in intensive/cardiovascular care units with a primary diagnosis of ADHF between 2013 and 2021. Clinical phenotypes, i.e., pulmonary congestion or tissue hypoperfusion, were defined through a comprehensive assessment of clinical signs and symptoms, vital signs, and laboratory findings. We assessed the frequency and temporal trends in phenotype-based drug utilization of vasoactive agents and investigated institutional characteristics associated with adopting the phenotype-based approach.

Throughout the study period, both overall and phenotype-based vasodilator utilization showed significant declines, with overall usage dropping from 61.4% in 2013 to 48.6% in 2021 (p for trend < 0.001). Conversely, no temporal changes were observed in overall inotrope/vasopressor utilization from 24.6% in 2013 to 25.8% in 2021 or the proportion of phenotype-based utilization. Notably, there was considerable variability in phenotype-based drug utilization among hospitals, ranging from 0% to 100%. Particularly, hospitals with a large number of board-certified cardiologists demonstrated reduced phenotype-based vasodilator utilization and phenotypically inappropriate inotrope/vasopressor utilization over time.

Substantial variability existed among hospitals in phenotype-based drug utilization of vasoactive agents for ADHF patients, highlighting the need for standardization in their adoption during hospitalization. a. What is known The absence of standardized drug utilization practices for acute decompensated heart failure contributes to notable variations in treatment approaches across different healthcare facilities, and these facility-specific differences have potential to influence patient outcomes. b. What the study adds This study demonstrated that, using a government-funded multicenter registry of hospitalized patients for acute decompensated heart failure, overall and phenotype-based inotrope/vasopressor utilization was relatively stable between 2013 and 2021, while significant declines in both overall and phenotype-based vasodilator utilization was observed over the same period. Significant variability was noted in the extent of phenotype-based drug utilization among hospitals, with the utilization rates ranging from 0% to 100%: Specifically, hospitals with a large number of board-certified cardiologists demonstrated gradual declines in phenotype-based vasodilator utilization and phenotypically inappropriate utilization of inotropes/vasopressors. Competing Interest Statement Dr. Kohsaka received an unrestricted research grant from Novartis and AstraZeneca. The remaining authors have no conflict of interest to disclose. Clinical Trial UMIN-CTR identifier, UMIN000013128 Funding Statement This work was supported by the Tokyo metropolitan government, which had no role in the execution of this study or the interpretation of the results. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study protocol was approved by the Tokyo CCU Network. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data availability The anonymized data that support the findings of this study are available from the corresponding author for reasonable requests.