Table 1
List of medications included for analysis by group, presentation and targeted doses used for analysis.
| MEDICATION GROUP | MEDICATION | PRESENTATION INCLUDED FOR ANALYSIS | 2022 AHA/ACC/HFSA GUIDELINE DEFINED OPTIMAL MEDICAL THERAPY DOSE (8) | OPTIMAL MEDICAL THERAPY DOSE SELECTED FOR THE STUDY |
|---|---|---|---|---|
| MRA | Spironolactone | 25 mg oral | 25–50 mg once daily | 25 mg once daily |
| Eplerenone | 25 mg oral | 50 mg once daily | 50 mg once daily | |
| SGLT2 inhibitors | Dapagliflozine | 10 mg oral | 10 mg once daily | 10 mg once daily |
| Empagliflozine | 10 mg oral | 10 mg once daily | 10 mg once daily | |
| Beta Blockers | Metoprolol | 95 mg oral* | 200 mg once daily | 190 mg daily* |
| Carvedilol | 12.5 mg oral | 25–50 mg twice daily | 25 mg twice a day | |
| Bisoprolol | 5 mg oral | 10 mg once daily | 10 mg a day | |
| ARNI | Sacubitril/Valsartan | 24.3/25.7 mg oral | 97 mg sacubitril and 10.3 mg valsartan twice daily | 97.2 mg sacubitril and 102.8 mg valsartan twice a day** |
| ACEI | Enalapril | 10 mg oral | 10–20 mg twice a day | 10 mg twice a day |
| Ramipril | 10 mg oral | 10 mg once daily | 10 mg once daily | |
| Lisinopril | 20 mg oral | 20–40 mg once daily | Lisinopril 40 mg once daily | |
| ARB | Valsartan | 80 mg oral | 160 mg twice daily | 160 mg twice daily |
| Losartan | 50 mg oral | 50–150 mg once daily | 150 mg once daily | |
| Candesartan | 8 mg oral | 32 mg once daily | 32 mg once daily |
[i] Abbreviations: ACEI: Angiotensin Converting Enzyme Inhibitors; ARB: Angiotensin Receptor Blocker; ARNI: Angiotensin Receptor – Neprilysin Inhibitor; BB: Beta blocker; MRA: Mineralocorticoid receptor antagonist; SGLT2i: Sodium-Glucose Co-Transporter 2 inhibitors.
* Metoprolol presentation available across Venezuela was 95 mg per tablet.
** Sacubitril/Valsartan presentation available across Venezuela was 24.3/25.7 mg.
Table 2
Cost of each GDMT and Affordability Ratio stratified by salary.
| MEDICINE GROUP | PRICE ($) | AFFORDABILITY RATIO | ||||||
|---|---|---|---|---|---|---|---|---|
| MEDIAN | MEAN +/– SD | MIN | MAX | MANAGERS* | PROFESSIONALS# | NON-PROFESSIONAL WORKERS ^ | RETIREMENT/MINIMUM WAGE Δ | |
| BB | 21.34 | 27.24 ± 18.77 | 1.28 | 79.92 | 1.49 | 2.26 | 3.19 | 168.74 |
| ARNI | 319.81 | 321.04 ± 33.43 | 287.02 | 361.09 | 17.48 | 26.52 | 37.47 | 1978.34 |
| ACEI | 8.23 | 15.85 ± 19.49 | 0.13 | 63.12 | 0.86 | 1.30 | 1.84 | 97.4 |
| ARB | 26.88 | 20.48 ± 11.92 | 2.18 | 43.97 | 1.25 | 1.90 | 2.68 | 141.95 |
| MRA | 11.33 | 12.31 ± 7.54 | 2.93 | 23.29 | 0.66 | 1.01 | 1.43 | 75.64 |
| SGLT2i | 41.33 | 37.28 ± 17.80 | 11.9 | 63 | 2.02 | 3.07 | 4.33 | 229.09 |
| Group A: ARNI + BB + MRA + SGLT2i | 393.81 | 398.99 ± 89.84 | 303.13 | 527.30 | 21.39 | 32.44 | 45.84 | 2420.06 |
| Group B: ACEI + BB + MRA + SGLT2i | 82.23 | 92.91 ± 19.44 | 16.24 | 229.33 | 4.46 | 6.77 | 9.57 | 505.32 |
| Group C: ARB + BB + MRA + SGLT2i | 100.88 | 97.53 ± 16.14 | 18.29 | 210.18 | 5.47 | 8.31 | 11.74 | 619.93 |
[i] Abbreviations: ACEI: Angiotensin Converting Enzyme Inhibitors; ARB: Angiotensin Receptor Blocker; ARNI: Angiotensin Receptor – Neprilysin Inhibitor; BB: Beta blocker; MRA: Mineralocorticoid receptor antagonist; SGLT2i: Sodium-Glucose Co-Transporter 2 inhibitors.
Type of employment mean monthly salary in United States Dollar ($): * = 405; # = 267; ^ = 189; Δ = 3.6.
Type of employment mean daily wages in United States Dollar ($): * = 18.4; # = 12.3; ^ = 8.59; Δ = 0.16.
Figure 1
Affordability ratios for Heart Failure Guideline Directed Medical Therapy. Y axis displays affordability ratio, X axis displays income type. Each combination of Guideline Directed Medical Therapy for Heart Failure is designated as Group A (ARNI, SGLT2i, BB, and MRA), Group B (ACEI, SGLT2i, BB, and MRA) and Group C (ARB, SGLT2i, BB, and MRA) according to signalized color. Segmented line represents the affordability ratio cut-off defined by the WHO/HAI.
Supplemental 1
Distribution of pharmacy retail stores by state and pharmacy network.
| FARMATODO | LOCATEL | FARMARKET | FARMACIAS SAAS | FARMAAHORRO | BADAN | FARMAPLUS | FARMAGO | BOTIQUERIA | FARMAVALOR | SUAF | RED VITAL | FARMACIA ACTUAL | TOTAL | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Amazonas | 5 | 2 | 3 | 1 | 2 | 1 | 2 | 0 | 1 | 1 | 1 | 1 | 0 | 20 |
| Anzoategui | 10 | 5 | 8 | 2 | 4 | 2 | 3 | 1 | 2 | 3 | 2 | 2 | 1 | 45 |
| Apure | 6 | 2 | 4 | 1 | 1 | 1 | 2 | 0 | 1 | 2 | 1 | 1 | 0 | 22 |
| Aragua | 12 | 6 | 9 | 3 | 5 | 3 | 4 | 1 | 2 | 4 | 3 | 3 | 1 | 56 |
| Barinas | 7 | 3 | 5 | 2 | 3 | 1 | 2 | 1 | 1 | 3 | 1 | 1 | 0 | 30 |
| Bolivar | 9 | 4 | 6 | 2 | 3 | 2 | 3 | 2 | 1 | 2 | 1 | 1 | 0 | 36 |
| Carabobo | 15 | 7 | 10 | 4 | 6 | 3 | 5 | 2 | 2 | 5 | 3 | 4 | 2 | 68 |
| Cojedes | 5 | 2 | 3 | 1 | 1 | 1 | 1 | 0 | 1 | 2 | 1 | 1 | 0 | 19 |
| Delta Amacuro | 4 | 1 | 2 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 1 | 0 | 13 |
| Falcon | 8 | 3 | 5 | 2 | 2 | 2 | 2 | 1 | 1 | 2 | 1 | 1 | 0 | 30 |
| Guarico | 4 | 2 | 3 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 0 | 17 |
| Lara | 11 | 5 | 8 | 3 | 4 | 2 | 3 | 1 | 2 | 4 | 2 | 2 | 1 | 48 |
| Merida | 8 | 4 | 6 | 2 | 3 | 2 | 2 | 1 | 1 | 3 | 2 | 1 | 1 | 36 |
| Miranda/Capital | 20 | 10 | 12 | 5 | 7 | 5 | 6 | 3 | 3 | 6 | 5 | 4 | 2 | 88 |
| Monagas | 7 | 3 | 5 | 2 | 2 | 2 | 2 | 1 | 1 | 2 | 1 | 1 | 0 | 29 |
| N Esparta | 6 | 2 | 4 | 1 | 2 | 1 | 2 | 1 | 1 | 2 | 1 | 1 | 1 | 25 |
| Portuguesa | 8 | 3 | 5 | 2 | 3 | 2 | 2 | 1 | 1 | 2 | 2 | 2 | 1 | 34 |
| Sucre | 6 | 3 | 4 | 1 | 2 | 1 | 2 | 1 | 1 | 2 | 1 | 1 | 1 | 26 |
| Tachira | 9 | 4 | 6 | 2 | 3 | 2 | 3 | 1 | 1 | 3 | 1 | 1 | 1 | 37 |
| Trujillo | 5 | 2 | 3 | 1 | 2 | 1 | 1 | 0 | 1 | 2 | 1 | 1 | 0 | 20 |
| Vargas | 4 | 2 | 3 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 18 |
| Yaracuy | 7 | 3 | 5 | 2 | 3 | 1 | 2 | 1 | 1 | 3 | 2 | 1 | 1 | 32 |
| Zulia | 18 | 8 | 12 | 4 | 7 | 4 | 5 | 2 | 2 | 5 | 3 | 3 | 1 | 74 |
| Total | 195 | 85 | 118 | 43 | 60 | 32 | 43 | 16 | 27 | 45 | 26 | 25 | 13 | 728 |