Pharmacist-led medication titration can help optimize heart failure therapy

Guideline-directed medical therapy in patients with heart failure with reduced ejection fraction (HFrEF) is recommended to reduce mortality and morbidity. Pharmacotherapy options which improve survival in HFrEF patients include angiotensin-converting-enzyme-inhibitors (ACEIs), angiotensin-receptor-blockers (ARBs), angiotensin receptor-neprilysin-inhibitors (ARNIs), beta-blockers, aldosterone antagonists, and more recently, sodium glucose co-transporter-2 (SGLT2) inhibitors. A new study evaluated the impact of a pharmacist-led heart failure medication-titration clinic on the proportion of patients in an ambulatory setting who achieve guideline-directed medical therapy in patients with HFrEF. Read: Low-dose aspirin for CVD and colorectal cancer prevention no longer recommended The primary outcome was to compare the proportion of patients who achieved triple guideline-directed medical therapy (ACEI or ARB or ARNI, plus beta-blocker, plus aldosterone antagonist) and quadruple guideline-directed medical therapy (triple therapy plus SGLT2 inhibitor) at 90-day post-enrollment (compared to baseline). The study, conducted at the Salem Veterans Affair Medical Center (Virginia), also compared combined heart failure-related hospitalization and emergency room visits 90 days pre-/post-enrollment. The analysis included 80 patients seen at least once in the heart failure medication titration clinic. The median age was 71 years and the majority of the patients were white males. Pharmacist interventions resulted in a significant improvement in the proportion of patients who achieved quadruple or triple guideline-directed medical therapy. The proportion of patients achieving guideline-directed medical therapy increased from 2.5% to 21.3% for quadruple therapy (p = 0.001), and from 18.8% to 36.3% for triple therapy (p = 0.020), 90 days post-enrollment compared to baseline. This study also showed a significant reduction in combined heart failure-related hospitalizations and emergency room visits at 90 days post-enrollment, compared to 90 days pre-enrollment; this was primarily driven by a reduction in emergency room visits. Pharmacist interventions were also found to improve patient quality of life and patient adherence to self-care. Pharmacists in this study received additional training in heart failure management. A care agreement was established between the pharmacy and cardiology service, allowing the trained pharmacists to initiate, titrate and adjust dosages, and discontinue heart failure medications. Pharmacists could also order lab tests, including a basic metabolic panel, liver function tests, and other tests as appropriate. Read: Novel drug proving beneficial in HCM patients The authors concluded that a pharmacist-led heart failure medication-titration clinic can significantly increase the proportion of patients who achieved triple and quadruple guideline-directed medical therapy at 90 days, reduce hospitalization/ER visits related to heart failure and improve patient quality of life. The authors contend that integrating pharmacists with expertise in heart failure management may reduce the burden on other providers and potentially increase access for new patients while simultaneously improving clinical outcomes. Reference 1. Patil T, Ali S, Kaur A, et al. Impact of pharmacist‑led heart failure clinic on optimization of guideline‑directed medical therapy (PHARM‑HF). J Cardiovasc Trans Res 2022; published online May 2, 2022. (accessed May 10, 2022).

Pharmacist-led medication titration can help optimize heart failure therapy

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