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

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Abstract
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. Methods: 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. Results: 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. Conclusions: 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. Key Learning Points: 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.

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