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Published on: February 13, 2021
Evaluation of Guideline-Directed Medical Therapy for Outpatients Living with Heart Failure with Reduced Ejection
Taylor McVannel1, Lori Albers2, Lynette Kosar3
1, BScPharm, ACPR, CDE, is the Manager of Pharmacy, Brandon Regional Health Centre, Brandon, Manitoba.
Insights
Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) was suboptimal in nearly half of patients. Intolerance was a key reason for not optimizing GDMT, highlighting a treatment gap.
Area of Science:
- Cardiology
- Pharmacology
- Health Services Research
Background:
- Pharmacotherapy, specifically guideline-directed medical therapy (GDMT) comprising four foundational medications, is central to managing heart failure with reduced ejection fraction (HFrEF).
- Current adherence to GDMT recommendations in clinical practice for HFrEF remains largely uncharacterized.
Purpose of the Study:
- To assess the proportion of HFrEF patients receiving optimized GDMT.
- To detail achieved dosages of foundational HFrEF medications.
- To identify documented reasons for suboptimal GDMT optimization.
Main Methods:
- A retrospective cohort study was conducted.
- Medical records of 129 HFrEF patients treated at the Regina Heart Function Clinic (HFC) as of December 31, 2021, were analyzed.
Main Results:
- Only 47.3% of patients were prescribed optimized GDMT.
- Optimized use varied by drug class: renin-angiotensin system inhibitors (82.2%), mineralocorticoid receptor antagonists (80.6%), beta-blockers (79.1%), and SGLT2 inhibitors (74.4%).
- Lack of documented rationale for suboptimal GDMT was common (35.8%); medication intolerance was the primary stated reason (33.0% for utilization, 57.6% for dosing).
- Pharmacists documented 553 patient care activities for 58.9% of patients outside scheduled appointments.
- 12.4% of patients experienced 31 heart failure-related hospitalizations in 2021.
Conclusions:
- A significant treatment gap exists in GDMT for HFrEF patients despite multidisciplinary care.
- Findings will guide improvements in clinic processes for identifying and optimizing GDMT in HFrEF patients.
- Enhanced pharmacist involvement may improve GDMT optimization and reduce hospitalizations.
Background:
Pharmacotherapy is the cornerstone of treatment for heart failure with reduced ejection fraction (HFrEF). The Canadian Cardiovascular Society and Canadian Heart Failure Society have defined guideline-directed medical therapy (GDMT) as 4 foundational medications. Despite strong recommendations for use of GDMT in HFrEF, current practice alignment with guidelines is unknown.
Objectives:
The primary objectives were to determine the proportion of patients for whom optimized GDMT for HFrEF was prescribed, to describe the doses of foundational medications achieved, and to describe any documented rationale limiting the optimization of GDMT. The secondary objectives were to describe documented pharmacist activities outside of scheduled multidisciplinary appointments at the heart function clinic (HFC) and to describe heart failure-related hospital encounters in 2021.
Methods:
A retrospective cohort study using medical records of patients with HFrEF who were receiving treatment at the Regina HFC as of December 31, 2021, was conducted.
Results:
Of the 129 patients included in the study, 61 (47.3%) were prescribed optimized GDMT. Specifically, within the individual foundational medication classes, 82.2% (106/129), 80.6% (104/129), 79.1% (102/129), and 74.4% (96/129) of patients received optimized therapy with a renin-angiotensin system inhibitor, mineralocorticoid receptor antagonist, β-blocker, and sodium-glucose cotransporter 2 inhibitor, respectively. Documented rationale was not available in 35.8% (38/106) of instances of suboptimal utilization of GDMT and in 41.7% (60/144) of instances of suboptimal dosing of GDMT. The most common documented rationale for suboptimal utilization was intolerance to the medication (33.0% [35/106]), and the most common rationale for suboptimal dosing was intolerance to dose increases (57.6% [83/144]). Pharmacists documented a total of 553 patient care activities for 58.9% (76/129) of the patients, outside scheduled multidisciplinary appointments in the HFC. Sixteen patients (12.4%) had heart failure-related hospital encounters a total of 31 times in 2021.
Conclusions:
Although many patients were receiving the benefits of multidisciplinary care at the Regina HFC, there remained a treatment gap in the use of GDMT for HFrEF. These findings will be used to inform strategies to improve clinic processes, including efficient identification of patients requiring optimization of GDMT, who would benefit the most from multidisciplinary care.
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