Guideline-directed Medical Therapy for Heart Failure in People with HIV: Prescription Intensity an

Cohort and study design

This analysis used data from the PATHWAYS study, a multi-institutional, retrospective investigation of underrepresented racial and ethnic minorities living with HIV. Adults with systolic heart failure (HF) were identified by ICD codes and included in the cohort. The study objective was to quantify the intensity of guideline-directed medical therapy (GDMT) prescribed after HF diagnosis and to identify patient-level factors associated with more or less intensive GDMT.

The design described in the abstract is retrospective and observational. Specifics such as the total number of participating institutions, the exact inclusion and exclusion criteria beyond ICD coding for systolic HF, and the time frame for patient selection were not reported in the abstract.

GDMT score construction and measurement

Investigators developed a composite GDMT score to represent the intensity of heart failure medical therapy prescribed to each patient. The score was dosage-weighted and scaled from 0% to 100%, where 100% corresponds to optimal guideline-directed therapy. The GDMT score was calculated using prescriptions documented in the year after HF diagnosis.

The abstract does not list the individual medication classes or agents included in the composite score, the dosing bands used for weighting, or how combination therapy was handled in the scoring algorithm. Details about validation of the score or sensitivity analyses were not provided in the abstract.

Patient demographics and baseline characteristics

The analytic cohort comprised 451 people with HIV and systolic HF. Median age was 54 years (interquartile range 47–62). Women represented 34.6% of the cohort. The population was predominantly Black, accounting for 96.6% of patients. Other baseline clinical characteristics beyond those reported below (for example, antiretroviral therapy status, CD4 count, or HF severity metrics) were not reported in the abstract.

GDMT prescription rates and cardiology access

Within the year following HF diagnosis, 85.8% of patients received at least one prescription for GDMT. Despite a high proportion receiving some GDMT, the mean composite GDMT score across the cohort was 30% with a standard deviation of 22%, indicating generally low intensity of therapy when dosing and comprehensive prescribing were taken into account.

Less than half of the cohort (45.5%) attended a cardiology clinic visit in the year after diagnosis. The abstract links clinic attendance to GDMT intensity (see associated factors below), but does not provide granular data on timing of visits, frequency, or whether cardiology involvement preceded initial prescribing.

Factors associated with GDMT intensity

Multivariable analyses examined patient factors associated with the GDMT score. The abstract reports the following associations using adjusted mean ratios (AMR) with 95% confidence intervals (CI):

• Older age was associated with lower GDMT scores (AMR = 0.96; 95% CI: 0.93–0.99).
• Severe renal disease was associated with lower GDMT scores (AMR = 0.84; 95% CI: 0.71–0.99).
• Diabetes mellitus was associated with higher GDMT scores (AMR = 1.33; 95% CI: 1.16–1.53).
• Prior myocardial infarction was associated with higher GDMT scores (AMR = 1.17; 95% CI: 1.02–1.35).
• Attendance at a cardiology clinic visit was associated with higher GDMT scores (AMR = 1.29; 95% CI: 1.13–1.47).

The abstract does not enumerate all covariates included in the multivariable model nor does it state the modeling approach in detail.

Interpretation and conclusions

The authors conclude that people with HIV and systolic HF in this multi-institutional cohort had low GDMT scores, implying suboptimal intensity of HF-directed medical care despite a high proportion having at least one GDMT prescription. Attendance at a cardiology clinic was associated with higher GDMT intensity, suggesting that specialty involvement may influence the comprehensiveness and dosing of evidence-based HF therapies in this population.

Observed associations indicate potential clinical priorities: older patients and those with severe renal disease received lower-intensity regimens, while comorbid cardiometabolic conditions (diabetes, prior myocardial infarction) and cardiology follow-up correlated with higher-intensity GDMT. The direction of these associations may reflect clinical contraindications, competing risks, differences in care pathways, or referral patterns; the abstract does not provide causal attribution.

Reported gaps and missing details

The abstract reports key cohort descriptors, GDMT uptake as any prescription, the mean composite GDMT score, and adjusted associations with GDMT intensity. However, several methodological and clinical details were not reported in the abstract and therefore cannot be summarized here. These include:

• The exact medication classes, agents, and dosing thresholds that comprised the dosage-weighted GDMT score.
• Timing, frequency, and nature of cardiology clinic visits relative to HF diagnosis and prescribing.
• Measures of HF severity (ejection fraction ranges, NYHA class) or HIV-specific clinical status (viral load, CD4 count, antiretroviral regimen).
• Information on adverse events, contraindications, or reasons for deviations from guideline dosing.
• Limitations of the study, including potential selection bias, misclassification based on ICD coding, or generalizability beyond the predominantly Black cohort.

These missing details were not provided in the abstract and would require consultation of the full manuscript for clarification.

Key takeaways

• In a predominantly Black cohort of people with HIV and systolic heart failure, intensity of guideline-directed medical therapy was low by a dosage-weighted composite metric despite a high rate of any GDMT prescription.
• Cardiology clinic attendance and certain cardiovascular comorbidities were associated with higher GDMT intensity, while older age and severe renal disease were associated with lower intensity.
• The abstract highlights potential gaps in HF care intensity among people with HIV and underscores the need for more detailed reporting to understand drivers of suboptimal GDMT in this high-risk population.