Triple and double therapy prior to MTEER independently linked to reduced risk of mortality or HFH one year after intervention

A recent analysis published in European Heart Journal has revealed a significant gap in the use of guideline-directed medical therapy (GDMT) among patients with mitral regurgitation (MR) who subsequently undergo transcatheter edge-to-edge repair (TEER) using the MitraClip device.

This study conducted by Anubodh Varshney and colleagues based on data from the Society of Thoracic Surgeons/American College of Cardiology TVT Registry, found that only one in five patients received the recommended triple therapy of renin-angiotensin-aldosterone system (RAAS) inhibitors or angiotensin receptor-neprilysin inhibitors (ARNI), beta-blockers, and mineralocorticoid receptor antagonists (MRA) before TEER.

To evaluate the real-world use of guideline-directed medical therapy (GDMT) among MR patients undergoing TEER, researchers analyzed data from the Society of Thoracic Surgeons/American College of Cardiology TVT Registry.

• The study included 4,199 MR patients with pre-procedure left ventricular ejection fraction (LVEF) less than 50% who underwent TEER. GDMT typically consists of renin-angiotensin-aldosterone system (RAAS) inhibitors or angiotensin receptor-neprilysin inhibitors (ARNI), beta-blockers, and mineralocorticoid receptor antagonists (MRA). However, only 19.2% of patients received triple therapy before TEER.
  
• For the subset of patients (n=2,014) eligible for one-year follow-up from 341 sites, the study revealed varying rates of one-year mortality or hospitalisation for heart failure (HFH) based on their GDMT regimen.
• Patients who received triple therapy exhibited the lowest composite rate (23.1%), followed by those on double therapy (24.8%), single therapy (35.7%), and no therapy (41.1%). These differences were statistically significant (P < 0.01), underscoring the impact of GDMT on patient outcomes.
• Furthermore, associations between GDMT and outcomes remained significant after accounting for pertinent clinical characteristics.
• Patients prescribed triple therapy demonstrated a lower risk (adjusted hazard ratio [aHR] 0.73, 95% CI 0.55-0.97), as did those on double therapy (aHR 0.69, 95% CI 0.56-0.86), in comparison to those receiving no or single therapy prior to MTEER.

These findings emphasise the independent influence of GDMT on reducing the risk of adverse events, such as mortality or HFH, one year after the intervention.

In summary, this study highlights a concerning pattern of suboptimal GDMT utilisation among HF patients undergoing TEER for FMR. Adherence to guideline recommendations for GDMT is critical, as it was associated with a reduced risk of adverse events, including mortality and HFH, one year after the intervention. Efforts to improve GDMT compliance in clinical practice are essential to enhance patient outcomes.

Reference:

Varshney, A. S., Shah, M., Vemulapalli, S., Kosinski, A., Bhatt, A. S., Sandhu, A. T., Hirji, S., DeFilippis, E. M., Shah, P. B., Fiuzat, M., O’Gara, P. T., Bhatt, D. L., Kaneko, T., Givertz, M. M., & Vaduganathan, M. Heart failure medical therapy prior to mitral transcatheter edge-to-edge repair: The STS/ACC transcatheter valve therapy registry. European Heart Journal,2023:ehad584. https://doi.org/10.1093/eurheartj/ehad584