EJECTION FRACTION-GUIDED PHARMACOTHERAPY IN CORONARY ARTERY DISEASE: A CROSS-SECTIONAL STUDY OF DIURETIC, RENIN–ANGIOTENSIN SYSTEM INHIBITOR, AND SACUBITRIL/VALSARTAN (ARNI) PRESCRIBING PATTERNS

Chetak Raghavana, Manasa K. S.*b, Laigin Sebastianb

ABSTRACT

Background: Left ventricular (LV) systolic function, quantified by ejection fraction (EF), is a key determinant of pharmacotherapy selection in coronary artery disease (CAD), guiding the use of diuretics, renin–angiotensin system (RAS) inhibitors, and, in patients with markedly reduced EF, the angiotensin receptor–neprilysin inhibitor (ARNI) sacubitril/valsartan. Real-world data on how closely EF-stratified prescribing in Indian tertiary-care practice aligns with guideline-directed therapy remain limited. Objective: To evaluate the distribution of ejection fraction categories among CAD patients and to characterize the utilization pattern of diuretics, ACE inhibitors/ARBs, and ARNI across these categories, alongside adherence to ACC/AHA guideline-directed prescribing. Methods: A hospital-based, cross-sectional, observational study was conducted over three months at a tertiary-care cardiology center in Kakinada, India. One hundred patients with confirmed CAD were enrolled by random sampling. Ejection fraction was determined by two-dimensional echocardiography, and prescription data for diuretics, RAS inhibitors, and ARNI were extracted from medical records and analyzed against EF category and ACC/AHA guideline concordance. Results: Mild-to-moderate LV dysfunction (EF 30–50%) was the most common finding, present in 38% of patients, followed by preserved EF ≥60% (29%), EF 50–60% (31%), and severely reduced EF ≤30% (2%). Diuretics were prescribed in 59% of patients overall and were the most frequently used drug class specifically among those with LV dysfunction, with torsemide (30.43%), spironolactone (29.34%), and furosemide (28.26%) the leading individual agents. ARNI (sacubitril/valsartan) was reserved exclusively for the 2% of patients with EF below 30%, reflecting guideline-concordant, EF-stratified escalation of therapy. Renin–angiotensin system blockade was achieved predominantly through ARBs (26% of patients; telmisartan 73.07% of ARB use) rather than ACE inhibitors (8% of patients). Guideline-directed prescribing, benchmarked against ACC/AHA recommendations, showed high concordance: statins 98.1%, dual antiplatelet therapy 97.5%, beta-blockers 96.8%, ACE inhibitors/ARBs 95.6%, and nitrates 84%. Conclusion: Pharmacotherapy in this CAD cohort was meaningfully stratified by ejection fraction, with diuretic intensification in LV dysfunction and reservation of ARNI for severely reduced EF, in keeping with ACC/AHA heart failure and CAD management guidelines. The comparatively lower use of ACE inhibitors relative to ARBs and the somewhat lower guideline concordance for nitrate therapy represent areas warranting closer prescribing review.

Keywords: Ejection fraction; left ventricular dysfunction; coronary artery disease; diuretics; renin–angiotensin system inhibitors; sacubitril/valsartan; ARNI; drug utilization.