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Maddox TM, Januzzi JL, Allen LA, Breathett K, Brouse S, Butler J, Davis LL, Fonarow GC, Ibrahim NE, Lindenfeld J, Masoudi FA, Motiwala SR, Oliveros E, Walsh MN, Wasserman A, Yancy CW, Youmans QR. 2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2024; 83:1444-1488. [PMID: 38466244 DOI: 10.1016/j.jacc.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
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Rossi LP, Granger BB, Bruckel JT, Crabbe DL, Graven LJ, Newlin KS, Streur MM, Vadiveloo MK, Walton-Moss BJ, Warden BA, Volgman AS, Lydston M. Person-Centered Models for Cardiovascular Care: A Review of the Evidence: A Scientific Statement From the American Heart Association. Circulation 2023; 148:512-542. [PMID: 37427418 DOI: 10.1161/cir.0000000000001141] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.
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Zheng J, Mednick T, Heidenreich PA, Sandhu AT. Pharmacist- and Nurse-Led Medical Optimization in Heart Failure: A Systematic Review and Meta-Analysis. J Card Fail 2023; 29:1000-1013. [PMID: 37004867 PMCID: PMC10524094 DOI: 10.1016/j.cardfail.2023.03.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Traditional approaches to guideline-directed medical therapy (GDMT) management often lead to delayed initiation and titration of therapies in patients with heart failure. This study sought to characterize alternative models of care involving nonphysician provider-led GDMT interventions and their associations with therapy use and clinical outcomes. METHODS We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies comparing nonphysician provider-led GDMT initiation and/or uptitration interventions vs usual physician care (PROSPERO ID: CRD42022334661). We queried PubMed, Embase, the Cochrane Library, and the World Health Organization International Clinical Trial Registry Platform for peer-reviewed studies from database inception to July 31, 2022. In the meta-analysis, we used RCT data only and leveraged random-effects models to estimate pooled outcomes. Primary outcomes were GDMT initiation and titration to target dosages by therapeutic class. Secondary outcomes included all-cause mortality and HF hospitalizations. RESULTS We reviewed 33 studies, of which 17 (52%) were randomized controlled trials with median follow-ups of 6 months; 14 (82%) trials evaluated nurse interventions, and the remainder assessed pharmacists' interventions. The primary analysis pooled data from 16 RCTs, which enrolled 5268 patients. Pooled risk ratios (RR) for renin-angiotensin system inhibitor (RASI) and beta-blocker initiation were 2.09 (95% CI 1.05-4.16; I2 = 68%) and 1.91 (95% CI1.35-2.70; I2 = 37%), respectively. Outcomes were similar for uptitration of RASI (RR 1.99, 95% CI 1.24-3.20; I2 = 77%) and beta-blocker (RR 2.22, 95% CI 1.29-3.83; I2 = 66%). No association was found with mineralocorticoid receptor antagonist initiation (RR 1.01, 95% CI 0.47-2.19). There were lower rates of mortality (RR 0.82, 95% CI 0.67-1.04; I2 = 12%) and hospitalization due to HF (RR 0.80, 95% CI 0.63-1.01; I2 = 25%) across intervention arms, but these differences were small and not statistically significant. Prediction intervals were wide due to moderate-to-high heterogeneity across trial populations and interventions. Subgroup analyses by provider type did not show significant effect modification. CONCLUSIONS Pharmacist- and nurse-led interventions for GDMT initiation and/or uptitration improved guideline concordance. Further research evaluating newer therapies and titration strategies integrated with pharmacist- and/or nurse-based care may be valuable.
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Affiliation(s)
- Jimmy Zheng
- Stanford University School of Medicine, Stanford, CA.
| | - Thomas Mednick
- Sutter Health, California Pacific Medical Center, San Francisco, CA
| | - Paul A Heidenreich
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
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Patil T, Ali S, Kaur A, Akridge M, Eppes D, Paarlberg J, Parashar A, Jarmukli N. Impact of Pharmacist-Led Heart Failure Clinic on Optimization of Guideline-Directed Medical Therapy (PHARM-HF). J Cardiovasc Transl Res 2022; 15:1424-1435. [PMID: 35501544 PMCID: PMC9060399 DOI: 10.1007/s12265-022-10262-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 04/20/2022] [Indexed: 12/16/2022]
Abstract
This prospective study included patients with heart failure (HF) with reduced ejection fraction (HFrEF) with LVEF < = 40% to evaluate the impact of pharmacist on guideline directed medical therapy (GDMT). The primary outcome was to compare proportion of triple GDMT achieved for Angiotensin-Converting-Enzyme-Inhibitors (ACEI)/Angiotensin-Receptor-Blockers (ARB)/Angiotensin-Receptor-Neprilysin-Inhibitors (ARNI), beta-blockers, aldosterone antagonists (AA), and quadruple GDMT which in additional to triple therapy, included Sodium glucose co-transporter 2 inhibitor (SGLT2i) at 90-day post-enrollment compared to baseline. Secondary endpoints included achieving target and/or maximally tolerated ACEI/ARB/ARNI and beta-blockers combined and individually as well as SGLT2i and AA GDMT at 90-day post-enrollment compared to baseline. We also compared combined and individual HF-related hospitalization/emergency room (ER) visits 90 days pre-/post-enrollment. Of the total 974 patients screened, 80 patients seen at least once in the heart failure medication titration clinic (HMTC) were included in the analysis. Median (IQR) age was 71 (57-69) years with majority white male. There was a significant improvement in the proportion of patients who achieved quadruple GDMT (p = 0.001) and triple GDMT (p-value = 0.020) at 90-day post-enrollment compared to baseline. The secondary GDMT outcomes were also significantly increased at 90 days post-enrollment compared to baseline. Significant difference in mean as well as proportion of combined HF-related hospitalization/ER-visits was found 90 days pre-/post-enrollment (p = 0.047). Our study found that pharmacist's intervention increased the proportion of patients who achieved GDMT at 90 days.
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Affiliation(s)
- Tanvi Patil
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Salihah Ali
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Alamdeep Kaur
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Meghan Akridge
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Davida Eppes
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - James Paarlberg
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Amitabh Parashar
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Nabil Jarmukli
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
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Mukhopadhyay A, Reynolds HR, Nagler AR, Phillips LM, Horwitz LI, Katz SD, Blecker S. Missed opportunities in medical therapy for patients with heart failure in an electronically-identified cohort. BMC Cardiovasc Disord 2022; 22:354. [PMID: 35927632 PMCID: PMC9354331 DOI: 10.1186/s12872-022-02734-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 06/10/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND National registries reveal significant gaps in medical therapy for patients with heart failure and reduced ejection fraction (HFrEF), but may not accurately (or fully) characterize the population eligible for therapy. OBJECTIVE We developed an automated, electronic health record-based algorithm to identify HFrEF patients eligible for evidence-based therapy, and extracted treatment data to assess gaps in therapy in a large, diverse health system. METHODS In this cross-sectional study of all NYU Langone Health outpatients with EF ≤ 40% on echocardiogram and an outpatient visit from 3/1/2019 to 2/29/2020, we assessed prescription of the following therapies: beta-blocker (BB), angiotensin converting enzyme inhibitor (ACE-I)/angiotensin receptor blocker (ARB)/angiotensin receptor neprilysin inhibitor (ARNI), and mineralocorticoid receptor antagonist (MRA). Our algorithm accounted for contraindications such as medication allergy, bradycardia, hypotension, renal dysfunction, and hyperkalemia. RESULTS We electronically identified 2732 patients meeting inclusion criteria. Among those eligible for each medication class, 84.8% and 79.7% were appropriately prescribed BB and ACE-I/ARB/ARNI, respectively, while only 23.9% and 22.7% were appropriately prescribed MRA and ARNI, respectively. In adjusted models, younger age, cardiology visit and lower EF were associated with increased prescribing of medications. Private insurance and Medicaid were associated with increased prescribing of ARNI (OR = 1.40, 95% CI = 1.02-2.00; and OR = 1.70, 95% CI = 1.07-2.67). CONCLUSIONS We observed substantial shortfalls in prescribing of MRA and ARNI therapy to ambulatory HFrEF patients. Subspecialty care setting, and Medicaid insurance were associated with higher rates of ARNI prescribing. Further studies are warranted to prospectively evaluate provider- and policy-level interventions to improve prescribing of these evidence-based therapies.
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Affiliation(s)
- Amrita Mukhopadhyay
- grid.137628.90000 0004 1936 8753Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Harmony R. Reynolds
- grid.137628.90000 0004 1936 8753Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Arielle R. Nagler
- grid.137628.90000 0004 1936 8753Ronald O. Perelman Department of Dermatology, New York University School Grossman of Medicine, New York, NY USA
| | - Lawrence M. Phillips
- grid.137628.90000 0004 1936 8753Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Leora I. Horwitz
- grid.137628.90000 0004 1936 8753Departments of Population Health and Medicine, New York University Grossman School of Medicine, 227 East 30th St., #637, New York, NY 10016 USA
| | - Stuart D. Katz
- grid.137628.90000 0004 1936 8753Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Saul Blecker
- Departments of Population Health and Medicine, New York University Grossman School of Medicine, 227 East 30th St., #637, New York, NY, 10016, USA.
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Kido K, Colvin BM, Broscious R, Bongiorni S, Sokos G, Kamal KM. Economic Impact of Ambulatory Clinical Pharmacists in an Advanced Heart Failure Clinic. Ann Pharmacother 2022; 56:10600280221075755. [PMID: 35168391 DOI: 10.1177/10600280221075755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Clinical pharmacists play pivotal roles in multidisciplinary heart failure (HF) teams through the management of HF pharmacotherapy, but no study has examined the economic impact of HF ambulatory clinical pharmacists in an advanced HF clinic. OBJECTIVE The objective of the study was to evaluate the economic impact of HF ambulatory clinical pharmacist interventions in an advanced HF clinic using a cost-benefit analysis. METHODS This prospective observational study detailed HF ambulatory clinical pharmacist interventions over 6 months in an advanced HF clinic in a single-center tertiary teaching hospital. The economic impact of the interventions was estimated based on the indirect cost savings with pharmacist interventions and direct cost savings recommendations. A cost-benefit analysis was performed to assess the cost of delivering the interventions compared with the benefits generated by clinical pharmacists. Results were reported as a benefit-cost ratio and net benefits. RESULTS HF ambulatory clinical pharmacists made a total of 2,361 provider-accepted interventions over 6 months. Overall, the 3 most common intervention types were medication reconciliation (28.7%), dose change (20.8%), and addition of medication (12.3%). Anticoagulation (21.2%) was the most common intervened class of medication, followed by sodium-glucose cotransporter-2 inhibitor (12.3%) and angiotensin receptor neprilysin inhibitor (9.2%). The total net benefits were $55,553.24 over 6 months and the benefit-cost ratio was 1.55. CONCLUSION AND RELEVANCE The addition of cardiology clinical pharmacists to an advanced HF clinic may be financially justified and cost-beneficial.
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Affiliation(s)
- Kazuhiko Kido
- Department of Clinical Pharmacy, School of Pharmacy, West Virginia University, Morgantown, WV, USA
| | - Bailey M Colvin
- Department of Pharmacy, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Rachael Broscious
- Department of Pharmacy, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Sydney Bongiorni
- School of Pharmacy, West Virginia University, Morgantown, WV, USA
| | - George Sokos
- Department of Medicine, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Khalid M Kamal
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV, USA
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Upton AJ, Tilton R, Ogedengbe O, Bankieris KR, Smith L, Trichon B, Thohan V, Kiser TH, Sleater LK. Impact of a pharmacist-inclusive post-discharge clinic on outcomes in heart failure patients with reduced ejection fraction: Rates of hospital readmission, emergency department visits, or death. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021; 4:1516-1523. [PMID: 34901761 DOI: 10.1002/jac5.1529] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Introduction Heart failure hospitalization is a hallmark of disease progression associated with increased morbidity and mortality. Benefits of multidisciplinary clinics have been established in the care of heart failure patients and can be particularly impactful post-hospital discharge. Objective This study aimed to investigate the impact of a clinical pharmacist-integrated model of care within a Heart Failure Bridge Clinic (HFBC) at a large tertiary care referral center. Methods In this single-center retrospective study, patients with left ventricular ejection fraction (LVEF) ≤40% discharged from Mission Hospital (Asheville, North Carolina) between August 2018 and July 2019 were screened. Patients in the HFBC arm had a clinic visit inclusive of a clinical pharmacist within 30 days of hospital discharge and were compared with a control group of patients with a usual care provider clinic visit. The HFBC provided clinical assessment, detailed heart failure education, and medication reconciliation and adjustment with an emphasis on optimization of Guideline Directed Medical Therapy (GDMT). Patients were followed for 90 days for the primary end point of hospitalization, emergency department (ED) visit, or death. Results A total of 1463 patients (HFBC, n = 307; control, n = 1156) comprised our final cohort. After accounting for baseline variables, 90-day cumulative probability of hospitalization, ED visit, or death favored HFBC patients (26% vs 32%, P = .0275). Comprehensive review of medications prior to and after HFBC appointment demonstrated significant alterations to therapies (30% GDMT addition, 27% GDMT titration, 7.2% discontinuation of medications associated with worsening heart failure, and 28% loop diuretic adjustment). Conclusion Clinical pharmacist-integrated HFBC allows for focused medication review and optimization and is associated with a 19% relative risk reduction in hospitalization, ED visit, or death at 90 days.
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Affiliation(s)
- Addison J Upton
- Department of Pharmacy, Mission Hospital, Asheville, North Carolina, USA
| | - Ryan Tilton
- Department of Pharmacy, Mission Hospital, Asheville, North Carolina, USA
| | - Opeyemi Ogedengbe
- Department of Pharmacy, Mission Hospital, Asheville, North Carolina, USA
| | - Kaitlyn R Bankieris
- Department of Data Science, Mission Hospital, Asheville, North Carolina, USA
| | - LaVone Smith
- Department of Cardiology, Mission Hospital, Asheville, North Carolina, USA
| | - Benjamin Trichon
- Department of Cardiology, Mission Hospital, Asheville, North Carolina, USA
| | - Vinay Thohan
- Department of Cardiology, Mission Hospital, Asheville, North Carolina, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
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Slade J, Lee M, Park J, Liu A, Heidenreich P, Allaudeen N. Harnessing the Potential of Primary Care Pharmacists to Improve Heart Failure Management. Jt Comm J Qual Patient Saf 2021; 48:25-32. [PMID: 34848159 DOI: 10.1016/j.jcjq.2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Improved utilization of guideline-directed medical therapy (GDMT) in the management of heart failure with reduced ejection fraction (HFrEF) can reduce mortality, reduce heart failure hospitalizations, and improve quality of life. Despite well-established clinical guidelines, these therapies remain significantly underprescribed. The goal of this intervention was to increase prescribing of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor neprilysin inhibitor (ARNI), and beta-blockers at ≥ 50% target doses. METHODS The study team identified key drivers to adequate dosing of GDMT: (1) frequent and reliable follow-up visits for titration opportunities, (2) identification of actionable patients for therapy initiation and titration, and (3) reduction in prescribing practice variability. The interventions were implemented at an outpatient clinical site and consisted of three main components: (1) establishing a pharmacist-led heart failure medication titration clinic, (2) creation of a standardized titration protocol, and (3) utilization of a patient dashboard to identify eligible patients. RESULTS For patients seen in the titration clinic, in 14 months, the mean dose per patient increased from 31.3% to 70.5% of target dose for ACEI/ARB/ARNI, and from 45.8% to 85.4% for beta-blockers. At this clinical site, the percentage of HFrEF patients receiving > 50% of targeted dose increased from 39.7% to 46.7% for ACEI/ARB/ARNI, and from 39.5% to 42.9% for beta-blockers. For ACEI/ARB/ARNI, use of target doses was 5.9% higher (95% confidence interval [CI] = 3.6%-8.3%, p < 0.0001) for the intervention site, 0.2% higher (95% CI = -2.2%-2.5%, p = 0.89) during the intervention period, and 10.4% higher (95% CI = 6.9%-13.9%, p < 0.0001) for the interaction (intervention site during the intervention time period). For beta-blockers, use of target doses was 1.0% higher (95% CI = -0.6%-2.6%, p = 0.20) for the intervention site, 0.8% lower (95% CI = -2.4%-0.8%, p = 0.29) for the intervention period, and 5.8% higher (95% CI = 3.5%-8.1%, p < 0.0001) for the interaction (intervention site during the intervention time period). CONCLUSION Through this project's interventions, the prescribing of ACEI/ARB/ARNI and beta-blocker therapy at ≥ 50% target doses for patients with HFrEF was increased. This study demonstrates the value of a multifaceted, team-based approach that integrates population-level interventions such as clinical dashboard management with a pharmacist-led heart failure medication titration clinic.
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Ahmed KO, Taj Eldin I, Yousif M, Albarraq AA, Yousef BA, Ahmed N, Babiker A. Clinical Pharmacist's Intervention to Improve Medication Titration for Heart Failure: First Experience from Sudan. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2021; 10:135-143. [PMID: 34796093 PMCID: PMC8593340 DOI: 10.2147/iprp.s341621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/05/2021] [Indexed: 12/28/2022] Open
Abstract
Background Medications known to improve outcomes in heart failure (HF) are either not prescribed or prescribed at sub-therapeutic doses. The addition of clinical pharmacists to the HF team positively impacts optimizing prognostic medications for a patient with HF with reduced ejection fraction (HFrEF). Objective To assess the intervention of the clinical pharmacist as part of the multidisciplinary (MD) team in up-titration to achieve target doses of key therapeutic agents for HFrEF. Methods This was a prospective one group pretest-posttest interventional study; a comparison of the target dose achievement of key therapeutic agents for HFrEF was performed before and after clinical pharmacist interventions. Results Out of 110 HFrEF patients, 57.3% were males, and the mean age of patients was 55.8 years (SD 12.6). Cardiomyopathy was the leading cause of HF. At baseline, 86% were on angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors (ACEIs/ARBs/ARNi) and 93.6% on beta blockers (BBs). At the end of study, the proportion of patients achieved the target dose was significantly increased (0 vs 77.4%, 6.8 vs 85.4%, and 0 vs 55.6%) for ACEIs, ARBs and ARNi, respectively, and (8.6% vs 66.1%; P = 0.001) for BBs. Moreover, the up-titration process was associated with significant improvement in most clinical as ejection fraction and New York Heart Association (NYHA) scale and laboratory characteristics. Conclusion As a part of the MD team in the outpatient HF clinic, the clinical pharmacists increased the percentage of HFrEF patients achieving the target or maximal doses of key therapeutic agents and improving clinical and laboratory parameters.
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Affiliation(s)
- Kannan O Ahmed
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan
| | - Imad Taj Eldin
- Department of Pharmacology, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan
| | - Mirghani Yousif
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan
| | - Ahmed A Albarraq
- Pharmacy Practice Research Unit, Department of Clinical Pharmacy, College of Pharmacy, Jazan University, Jazan, Saudi Arabia
| | - Bashir A Yousef
- Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
| | - Nasrein Ahmed
- Department of Cardiology, Ahmed Gasim Cardiac Surgery and Renal Transplantation Centre, Khartoum, Sudan
| | - Anas Babiker
- Department of Cardiology, Royal Care International Hospital, Khartoum, Sudan
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Wong EC, Fordyce CB, Wong G, Lee T, Perry‐Arnesen M, Mackay M, Singer J, Cairns JA, Turgeon RD. Predictors of the Use of Mineralocorticoid Receptor Antagonists in Patients With Left Ventricular Dysfunction Post-ST-Segment-Elevation Myocardial Infarction. J Am Heart Assoc 2021; 10:e019167. [PMID: 34227405 PMCID: PMC8483484 DOI: 10.1161/jaha.120.019167] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/22/2021] [Indexed: 01/14/2023]
Abstract
Background Guidelines recommend mineralocorticoid receptor antagonist (MRA) use in patients with left ventricular ejection fraction ≤40% following a myocardial infarction plus heart failure or diabetes mellitus, based on mortality benefit in the EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study) trial. The objective of this study was to evaluate the real-world utilization of MRAs for patients with ST-segment-elevation myocardial infarction (STEMI) with left ventricular dysfunction. Methods and Results The prospective, population-based, Vancouver Coastal Health Authority STEMI database was linked with local outpatient cardiology records from 2007 to 2018. EPHESUS criteria were used to define post-STEMI MRA eligibility (left ventricular ejection fraction ≤40% plus clinical heart failure or diabetes mellitus, and no dialysis-dependent renal dysfunction). The primary outcome was MRA prescription among eligible patients at discharge and the secondary outcome was MRA prescription within 3 months postdischarge. Of 2691 patients with STEMI, 317 (12%) were MRA eligible, and 70 (22%) eligible patients were prescribed an MRA at discharge. Among eligible patients with no MRA at discharge, 12/126 (9.5%) with documented postdischarge follow-up were prescribed an MRA within 3 months. In multivariable analysis, left ventricular ejection fraction (odds ratio [OR], 1.55 per 5% left ventricular ejection fraction decrease; 95% CI, 1.26-1.90) and calendar year (OR, 1.23 per year, 95% CI, 1.11-1.37) were associated with MRA prescription at discharge. Other prespecified variables were not associated with MRA prescription. Conclusions In this contemporary STEMI cohort, only 1 in 4 MRA-eligible patients were prescribed an MRA within 3 months following hospitalization despite high-quality evidence for use. Novel decision-support tools are required to optimize pharmacotherapy decisions during hospitalization and follow-up to target this gap in post-STEMI care.
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Affiliation(s)
- Eric C. Wong
- Division of General Internal MedicineDepartment of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Christopher B. Fordyce
- Division of CardiologyDepartment of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Centre for Health Evaluation and Outcome SciencesProvidence Health Care Research InstituteUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Vancouver Coastal Health AuthorityVancouverBritish ColumbiaCanada
| | - Graham Wong
- Division of CardiologyDepartment of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Vancouver Coastal Health AuthorityVancouverBritish ColumbiaCanada
| | - Terry Lee
- Centre for Health Evaluation and Outcome SciencesProvidence Health Care Research InstituteUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | | | - Martha Mackay
- Centre for Health Evaluation and Outcome SciencesProvidence Health Care Research InstituteUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- School of NursingUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- St. Paul's Hospital Heart CentreVancouverBritish ColumbiaCanada
| | - Joel Singer
- Centre for Health Evaluation and Outcome SciencesProvidence Health Care Research InstituteUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- School of Population and Public HealthUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - John A. Cairns
- Division of CardiologyDepartment of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Ricky D. Turgeon
- Division of CardiologyDepartment of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Centre for Health Evaluation and Outcome SciencesProvidence Health Care Research InstituteUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Faculty of Pharmaceutical SciencesUniversity of British ColumbiaVancouverBritish ColumbiaCanada
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Cao VF, Cowley E, Koshman SL, MacGillivray J, Sidsworth M, Turgeon RD. Pharmacist‐led optimization of heart failure medications: A systematic review. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Vivien F.S. Cao
- Department of Pharmacy Vancouver General Hospital Vancouver Canada
| | - Emily Cowley
- Department of Pharmacy Alberta Health Services Edmonton Canada
| | - Sheri L. Koshman
- Division of Cardiology, Department of Medicine University of Alberta Edmonton Canada
| | | | | | - Ricky D. Turgeon
- Faculty of Pharmaceutical Sciences University of British Columbia Vancouver Canada
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12
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Maddox TM, Januzzi JL, Allen LA, Breathett K, Butler J, Davis LL, Fonarow GC, Ibrahim NE, Lindenfeld J, Masoudi FA, Motiwala SR, Oliveros E, Patterson JH, Walsh MN, Wasserman A, Yancy CW, Youmans QR. 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction. J Am Coll Cardiol 2021; 77:772-810. [DOI: 10.1016/j.jacc.2020.11.022] [Citation(s) in RCA: 233] [Impact Index Per Article: 77.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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13
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Guideline-led prescribing to ambulatory heart failure patients in a cardiology outpatient service. Int J Clin Pharm 2021; 43:1082-1089. [PMID: 33411177 DOI: 10.1007/s11096-020-01220-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
Background Guidelines recommend heart failure (HF) patients be treated with multiple medications at doses proven to improve clinical outcomes. Objective To study guideline-led prescribing in an Irish outpatient HF population. Setting Cardiology Outpatient Clinic, Mercy University Hospital, Cork, Ireland. Methods Guideline-led prescribing was assessed using the Guideline Adherence Index (GAI-3), that considered the prescribing of ACE inhibitors and angiotensin receptor blockers; beta-blockers and mineralocorticoid receptor antagonists. The GAI-based target dose was calculated based on the prescription of ≥ 50% of the guideline-recommended target dose of each of the three GAI medications to HF patients with ejection fraction ≤ 40%. High-GAI was achieved by prescription of ≥ 2 GAI medicines. Potentially inappropriate prescribing was assessed using a HF-specific tool. Main outcome measure Heart failure guideline-led prescribing assessed using the GAI-3. Results A total of 127 HF patients, mean age 71.7 ± 13.1 years, were identified in the study. Seventy-one patients had ejection fraction ≤ 40%. Population mean GAI-3 was 65.8%. When contraindications to therapy are considered, the adjusted GAI-3 increased to 72.9%. The target dose GAI was 18.5%. High-GAI management was prescribed to 54 patients (76.1%). A potentially inappropriate medicine in HF was prescribed to 14 (19.7%) patients. Conclusion Most HF patients with ejection fraction ≤ 40% in this setting received optimal guideline-led prescribing however the proportion of patients achieving the target doses of these agents was suboptimal.
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14
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Affiliation(s)
- Arden R. Barry
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC
| | - Ricky D. Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC
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15
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El Hadidi S, Rosano G, Tamargo J, Agewall S, Drexel H, Kaski JC, Niessner A, Lewis BS, Coats AJS. Potentially Inappropriate Prescriptions in Heart Failure with Reduced Ejection Fraction (PIP-HFrEF). EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 8:187-210. [PMID: 32941594 DOI: 10.1093/ehjcvp/pvaa108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/12/2020] [Accepted: 09/04/2020] [Indexed: 12/13/2022]
Abstract
Heart failure (HF) is a chronic debilitating and potentially life-threatening condition. Heart Failure patients are usually at high risk of polypharmacy and consequently, potentially inappropriate prescribing leading to poor clinical outcomes. Based on the published literature, a comprehensive HF-specific prescribing review tool is compiled to avoid medications that may cause HF or harm HF patients and to optimize the prescribing practice of HF guideline-directed medical therapies. Recommendations are made in line with the last versions of ESC guidelines, ESC position papers, scientific evidence, and experts' opinions.
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Affiliation(s)
- Seif El Hadidi
- Faculty of Pharmaceutical Sciences and Pharmaceutical Industries, Future University in Egypt, New Cairo, Egypt
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy.,Cardiovascular Clinical Academic Group, St George's Hospitals NHS Trust University of London, London, UK
| | - Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, Madrid, Spain
| | - Stefan Agewall
- Department of Cardiology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Heinz Drexel
- VIVIT Institute, Landeskrankenhaus Feldkirch, Austria
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London
| | - Alexander Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, Technion-IIT, Haifa, Israel
| | - Andrew J S Coats
- Centre of Clinical and Experimental Medicine, IRCCS San Raffaele Pisana, Rome, Italy
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16
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Jarjour M, Henri C, de Denus S, Fortier A, Bouabdallaoui N, Nigam A, O'Meara E, Ahnadi C, White M, Garceau P, Racine N, Parent MC, Liszkowski M, Giraldeau G, Rouleau JL, Ducharme A. Care Gaps in Adherence to Heart Failure Guidelines: Clinical Inertia or Physiological Limitations? JACC-HEART FAILURE 2020; 8:725-738. [PMID: 32800509 DOI: 10.1016/j.jchf.2020.04.019] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/13/2020] [Accepted: 04/30/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES This study evaluated the impact of clinical and physiological factors limiting treatment optimization toward recommended medical therapy in heart failure (HF). BACKGROUND Although guidelines aim to assist physicians in prescribing evidence-based therapies and to improve outcomes of patients with HF and reduced ejection fraction (HFrEF), gaps in clinical care persist. METHODS Medical records of all patients with HFrEF followed for at least 6 months at the authors' HF clinic (n = 511) allowed for drug optimization and were reviewed regarding the prescription rates of recommended pharmacological agents and devices (implantable cardioverter-defibrillator [ICD] or cardiac resynchronization therapy [CRT]). Then, an algorithm integrating clinical (New York Heart Association [NYHA] functional class, heart rate, blood pressure and biologic parameters (creatinine, serum potassium) based on the inclusion/exclusion criteria of landmark trials guiding these recommendations) was applied for each agent and device to identify potential explanations for treatment gaps. RESULTS Gross prescription rates were high for beta-blockers (98.6%), mineralocorticoid receptor antagonist (MRA) (93.4%), vasodilators (90.3%), ICDs (75.1%), and CRT (82.1%) among those eligible, except for ivabradine (46.3%, n = 41). However, achievement of target physiological doses was lower (beta-blockers, 67.5%; MRA, 58.9%; and vasodilators, 63.4%), and one-fifth of patient dosages were still being up-titrated. Suboptimal doses were associated with older age (odds ratio [OR]: 1.221; p < 0.0001) and history of stroke or transient ischemic attack (TIA) (no vs. yes, OR: 0.264; p = 0.0336). CONCLUSIONS Gaps in adherence to guidelines exist in specialized HF setting and are mostly explained by limiting physiological factors rather than inertia. Older age and history of stroke/TIA, potential markers of frailty, are associated with suboptimal doses of guideline-directed medical therapy, suggesting that an individualized rather than a "one-size-fits-all" approach may be required.
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Affiliation(s)
- Marilyne Jarjour
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Christine Henri
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Simon de Denus
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Annik Fortier
- Biostatistics, Montreal Health Innovation Coordinating Center, Montreal, Quebec, Canada
| | | | - Anil Nigam
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Eileen O'Meara
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Charaf Ahnadi
- Collaborative Research for Effective Diagnostics, University Hospital Center of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michel White
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Patrick Garceau
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Normand Racine
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | | | - Mark Liszkowski
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | | | | | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada.
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17
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Puckett C, Goodlin SJ. A Modern Integration of Palliative Care Into the Management of Heart Failure. Can J Cardiol 2020; 36:1050-1060. [DOI: 10.1016/j.cjca.2020.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/05/2020] [Accepted: 05/05/2020] [Indexed: 12/14/2022] Open
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18
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Oliver-McNeil S, Bowers M, LaRue SJ, Vader J, DeVore AD, Granger BB. Benefits of Optimizing Heart Failure Medication Dosage. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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19
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Barry AR, Lee C. Pharmacist- or Nurse Practitioner-Led Assessment and Titration of Sacubitril/Valsartan in a Heart Failure Clinic: A Cohort Study. Can J Hosp Pharm 2020; 73:186-192. [PMID: 32616944 PMCID: PMC7308157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Sacubitril/valsartan is a first-in-class angiotensin receptor-neprilysin inhibitor indicated in the management of heart failure with reduced ejection fraction, based on the results of the PARADIGM-HF trial. Practice-based studies are needed to validate its effect in real-world settings. Clinical pharmacists are ideally situated to assess and titrate sacubitril/valsartan. OBJECTIVE To evaluate the utilization, safety, and tolerability of sacubitril/valsartan in a multidisciplinary heart failure clinic, with assessment and titration by a clinical pharmacist or a nurse practitioner. METHODS A retrospective cohort study was conducted at a heart failure clinic in Abbotsford, Canada. Included were adult patients with heart failure who were currently or formerly taking sacubitril/valsartan. Data collected for the period October 2015 to February 2019 included patient characteristics, New York Heart Association (NYHA) classification, concurrent medications, sacubitril/valsartan dose, adverse effects, and discontinuation rate. RESULTS In total, 128 patients were included. Mean age was 70.1 years, 98 (77%) of the patients were men, and 79 (62%) had NYHA class 2 heart failure. The clinical pharmacist managed care for 78 (61%) of the patients, and the nurse practitioner managed care for 50 (39%). Forty-one (32%) of the patients met modified PARADIGM-HF inclusion criteria. Eighty-five (66%) of the patients achieved the target dose of sacubitril/valsartan, with similar proportions for the clinical pharmacist and nurse practitioner groups, over a mean of 2.2 clinic visits. Patients who achieved the sacubitril/valsartan target dose, relative to those who did not, were significantly younger and had higher mean systolic blood pressure at baseline. Twenty-nine percent of patients (35/119) had an improvement in NYHA classification from before initiation of sacubitril/valsartan to achievement of target or maximally tolerated dose. Eighty-five (66%) of the patients experienced an adverse effect, primarily hypotension, and 12 (9%) required a dose reduction. Only 9 (7%) patients discontinued therapy. CONCLUSIONS This study demonstrates the real-world safety and tolerability of sacubitril/valsartan in the treatment of heart failure, and reinforces that clinical pharmacists can effectively assess and titrate medications in a multidisciplinary heart failure clinic.
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Affiliation(s)
- Arden R Barry
- , BSc, BSc(Pharm), PharmD, ACPR, is a Clinical Pharmacy and Research Specialist with the Abbotsford Regional Hospital and Cancer Centre, Lower Mainland Pharmacy Services, Abbotsford, British Columbia, and Assistant Professor (Partner) with the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Candy Lee
- , BSc(Pharm), ACPR, is Clinical Pharmacist with the Surrey Memorial Hospital, Lower Mainland Pharmacy Services, Surrey, British Columbia
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20
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Blood AJ, Fischer CM, Fera LE, MacLean TE, Smith KV, Dunning JR, Bosque-Hamilton JW, Aronson SJ, Gaziano TA, MacRae CA, Matta LS, Mercurio-Pinto AA, Murphy SN, Scirica BM, Wagholikar K, Desai AS. Rationale and design of a navigator-driven remote optimization of guideline-directed medical therapy in patients with heart failure with reduced ejection fraction. Clin Cardiol 2019; 43:4-13. [PMID: 31725920 PMCID: PMC6954374 DOI: 10.1002/clc.23291] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 12/11/2022] Open
Abstract
Although optimal pharmacological therapy for heart failure with reduced ejection fraction (HFrEF) is carefully scripted by treatment guidelines, many eligible patients are not treated with guideline‐directed medical therapy (GDMT) in clinical practice. We designed a strategy for remote optimization of GDMT on a population scale in patients with HFrEF leveraging nonphysician providers. An electronic health record‐based algorithm was used to identify a cohort of patients with a diagnosis of heart failure (HF) and ejection fraction (EF) ≤ 40% receiving longitudinal follow‐up at our center. Those with end‐stage HF requiring inotropic support, mechanical circulatory support, or transplantation and those enrolled in hospice or palliative care were excluded. Treating providers were approached for consent to adjust medical therapy according to a sequential, stepped titration algorithm modeled on the current American College of Cardiology (ACC)/American Heart Association (AHA) HF Guidelines within a collaborative care agreement. The program was approved by the institutional review board at Brigham and Women's Hospital with a waiver of written informed consent. All patients provided verbal consent to participate. A navigator then facilitated medication adjustments by telephone and conducted longitudinal surveillance of laboratories, blood pressure, and symptoms. Each titration step was reviewed by a pharmacist with supervision as needed from a nurse practitioner and HF cardiologist. Patients were discharged from the program to their primary cardiologist after achievement of an optimal or maximally tolerated regimen. A navigator‐led remote management strategy for optimization of GDMT may represent a scalable population‐level strategy for closing the gap between guidelines and clinical practice in patients with HFrEF.
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Affiliation(s)
- Alexander J Blood
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Christina M Fischer
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Liliana E Fera
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Taylor E MacLean
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katelyn V Smith
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jacqueline R Dunning
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Samuel J Aronson
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.,Research Information Science and Computing, Partners Healthcare, Somerville, Massachusetts
| | - Thomas A Gaziano
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Calum A MacRae
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lina S Matta
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ana A Mercurio-Pinto
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shawn N Murphy
- Massachusetts General Hospital, Boston, Massachusetts.,Research Information Science and Computing, Partners Healthcare, Somerville, Massachusetts
| | - Benjamin M Scirica
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kavishwar Wagholikar
- Massachusetts General Hospital, Boston, Massachusetts.,Research Information Science and Computing, Partners Healthcare, Somerville, Massachusetts
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
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21
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The Impact of Pharmacist-Based Services Across the Spectrum of Outpatient Heart Failure Therapy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:59. [DOI: 10.1007/s11936-019-0750-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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22
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Effectiveness of the Pharmacist-Involved Multidisciplinary Management of Heart Failure to Improve Hospitalizations and Mortality Rates in 4630 Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Card Fail 2019; 25:744-756. [DOI: 10.1016/j.cardfail.2019.07.455] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 07/03/2019] [Accepted: 07/12/2019] [Indexed: 12/28/2022]
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23
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Di Palo KE, Patel K, Kish T. Risk Reduction to Disease Management: Clinical Pharmacists as Cardiovascular Care Providers. Curr Probl Cardiol 2019; 44:276-293. [DOI: 10.1016/j.cpcardiol.2018.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 07/21/2018] [Indexed: 01/22/2023]
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24
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Utilization and Dose Optimization of Angiotensin-Converting Enzyme Inhibitors among Heart Failure Patients in Southwest Ethiopia. BIOMED RESEARCH INTERNATIONAL 2019; 2019:9463872. [PMID: 31179336 PMCID: PMC6507240 DOI: 10.1155/2019/9463872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 04/17/2019] [Indexed: 12/28/2022]
Abstract
Background Optimal use of angiotensin-converting enzyme inhibitors (ACEIs) is crucial to improve the treatment outcome in heart failure patients. However, little is known about the optimal use of ACEIs among heart failure patients in our setting. Therefore, our study aimed to investigate the utilization and optimal dosing of ACEIs and associated factors in heart failure patients. Method A cross-sectional study was conducted on randomly selected patients with heart failure between February 2016 and June 2016 at ambulatory care clinic of Jimma University Medical Center, Ethiopia. Data were collected through patient interview and review of medical records. Binary logistic regression analysis was done to identify factors associated with utilization and optimal dosing of ACEIs. Results A total of 308 patients were included in the final analysis of this study. The mean (±standard deviation) age of the patients was 52.3 ±15.5 years. Out of the total, 74.7% of the patients were receiving ACEIs. Among the patients who were receiving ACEIs, only 35.7% were taking optimal dose. New York Heart Association (NYHA) class III (Adjusted odds ratio (AOR):0.12, 95% confidence interval (CI):0.02–0.98), valvular heart disease (AOR: 0.27, 95% CI: 0.13-0.56), hypertension (AOR: 5.82, 95% CI: 2.16-15.71), and diabetes mellitus (AOR: 3.84, 95% CI: 1.07-13.86) were significantly associated with the use of ACEIs, whereas age ≥65 (AOR: 2.61, 95%CI: 1.20-5.64), previous hospitalization for heart failure (AOR: 2.08, 95%CI: 1.11-3.92), diuretic use (AOR: 5.60, 95%CI: 2.75-11.40), and dose of furosemide >40mg (AOR: 9.80, 95%CI: 3.00-31.98) were predictors of suboptimal dosing of ACEIs. Conclusion Although majority of patients were receiving ACEIs, only about one-third were using optimal dosage. Valvular heart disease and NYHA class III were negatively associated with the use of ACEIs while previous hospitalization for heart failure, old age, diuretic use, and diuretic dose were predictors of suboptimal dosing of ACEIs. Therefore, more effort needs to be done to minimize the potentially modifiable risk factors of suboptimal use of ACEIs therapy in heart failure patients.
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25
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Bress AP, King JB. Optimizing Medical Therapy in Chronic Worsening HFrEF: A Long Way to Go. J Am Coll Cardiol 2019; 73:945-947. [PMID: 30819363 PMCID: PMC6642611 DOI: 10.1016/j.jacc.2018.12.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 12/13/2018] [Indexed: 01/14/2023]
Affiliation(s)
- Adam P Bress
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah.
| | - Jordan B King
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
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