Disparities in prescriptions among Danish heart failure patients: a national longitudinal cohort study

Background Angiotensin receptor-neprilysin inhibitors (ARNi) and sodium-glucose co-transporter 2 inhibitors (SGLT2i) have a Class I indication in the European Society of Cardiology’s guidelines for the diagnosis and treatment of acute and chronic heart failure due to benefits in symptom management, rehospitalization rates, and mortality in heart failure. The aim of this study was to investigate demographic, geographic and socioeconomic disparities in prescriptions for ARNi and SGLT2i for heart failure patients in a universal healthcare system. Methods We used national registers to identify all Danish heart failure patients who were diagnosed on or after the updated clinical guidelines by the European Society of Cardiology (14 July 2016 for ARNi and 27 August 2021 for SGLT2i). Patients were followed until redemption of prescription, emigration, death or censoring on 30 June 2022, whichever came first. The Aalen-Johansen estimator and Cox proportional hazard models were used for individual analysis of ARNi (n=43 625) and SGLT2i (n=2819). Results The following factors were associated with lack of prescriptions for ARNi and SGLT2i: being women, older age, living alone and being non-native Danish or descendant. HRs ranged from 0.31 (95% CI 0.28 to 0.36) to 0.86 (95% CI 0.80 to 0.93) for ARNi and 0.49 (95% CI 0.41 to 0.58) to 0.93 (95% CI 0.72 to 1.20) for SGLT2i. Prescriptions for both ARNi and SGLT2i showed a social gradient, with the gradient for ARNi being statistically significant. Conclusions Substantial disparity was found in prescriptions for the potentially life-saving medications, with lack of prescriptions being associated with lower education, lower income and several demographic characteristics.