# Extent and predictors of guideline-directed medical therapy optimization during cardiac rehabilitation in patients with heart failure

## TL;DR

Cardiac rehabilitation helps optimize heart failure drug therapy, especially in patients with hypertension, while high diuretic doses may hinder optimization.

## Contribution

Quantifies GDMT optimization during cardiac rehabilitation and identifies clinical predictors like hypertension and diuretic use.

## Key findings

- Significant uptitration of major heart failure drug classes occurred during cardiac rehabilitation.
- Hypertensive patients showed the greatest GDMT optimization.
- Higher diuretic doses and prior specialist care were linked to less optimization.

## Abstract

Cardiac rehabilitation (CR) may offer a structured framework for guideline-directed medical therapy (GDMT) optimization, but its real-world impact is uncertain. We aimed to quantify GDMT optimization and identify its clinical predictors during CR.

This retrospective single-centre study included patients hospitalized for acute HF with reduced (HFrEF) or mildly reduced (HFmrEF) ejection fraction who subsequently underwent first inpatient or ambulatory CR at Nancy University Hospital (2021–2024). Changes in GDMT optimization were evaluated using the HF prescription and the KCMO scores and expressed as adjusted standardized differences (ASD). Multivariable linear regression identified independent predictors of optimization.

Among the 106 patients included (84 % HFrEF, mean age 59 years; 75 % male), baseline GDMT use was high, but doses were suboptimal. During CR, significant uptitration occurred across all major drug classes, including angiotensin receptor–neprilysin inhibitors (ASD: +22 %), beta-blockers (ASD: +21 %), mineralocorticoid receptor antagonists (ASD: +43 %), and sodium–glucose cotransporter 2 inhibitors (ASD: +45 %) (all p < 0.001). Overall GDMT optimization improved significantly, as evidenced by increases in both the KCMO (ASD: +39.9) and HF prescription (ASD: +1.27) scores (both p < 0.001), with consistent effects across inpatient and ambulatory settings. In multivariable analysis, higher loop-diuretic dose and prior treatment by HF specialists were associated with less optimization, whereas hypertension predicted greater intensification.

Cardiac rehabilitation after HF hospitalization promoted substantial GDMT optimization, especially in hypertensive patients. Higher loop-diuretic dose at admission predicted less optimization, suggesting that minimizing diuretic doses may ease GDMT titration.

•Cardiac rehabilitation enables structured GDMT optimization after acute HF.•Significant uptitration observed across all major HF drug classes.•Hypertensive patients achieved the greatest GDMT optimization.•Higher diuretic dose and prior specialist care associated with less optimization opportunity.

Cardiac rehabilitation enables structured GDMT optimization after acute HF.

Significant uptitration observed across all major HF drug classes.

Hypertensive patients achieved the greatest GDMT optimization.

Higher diuretic dose and prior specialist care associated with less optimization opportunity.