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Differences in the Approach to Guideline-Directed Medical Therapy in Patients with Heart Failure with Reduced
Lana Alhashimi1, David J Cordwin1, Jessica Guidi2,3
1College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA.
Insights
Pharmacists are more likely to adjust guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) than physicians. This study highlights their key role in optimizing GDMT prescribing for better patient outcomes.
Area of Science:
- Cardiology
- Pharmacology
- Internal Medicine
Background:
- Guideline-directed medical therapy (GDMT) significantly improves outcomes in patients with heart failure with reduced ejection fraction (HFrEF).
- Suboptimal prescribing of GDMT remains a challenge in clinical practice.
- Understanding prescribing patterns among different healthcare professionals is crucial for improving GDMT implementation.
Purpose of the Study:
- To survey cardiologists, internists, and pharmacists regarding their approach to GDMT prescribing in HFrEF.
- To compare the GDMT prescribing behaviors of pharmacists versus physicians (cardiologists and internists).
Main Methods:
- A survey with 20 clinical vignettes of HFrEF patients was administered to 127 cardiologists, 68 internists, and 89 pharmacists.
- Responses regarding GDMT adjustments were collected and dichotomized.
- A mixed-effect model was used to analyze the odds of changing GDMT between pharmacists and physicians.
Main Results:
- Pharmacists were more likely than internists to make GDMT changes (92.1% vs 82%; OR 3.02).
- Pharmacists demonstrated higher likelihoods in initiating beta-blockers and mineralocorticoid receptor antagonists compared to physicians.
- Pharmacists showed greater propensity than physicians to titrate beta-blockers and angiotensin receptor-neprilysin inhibitors (ARNI).
Conclusions:
- Pharmacists exhibit a higher likelihood of making GDMT adjustments for HFrEF compared to internists and cardiologists.
- Pharmacists' prescribing preferences include initiating spironolactone and titrating beta-blockers.
- Pharmacists are more likely than internists to initiate beta-blockers and titrate ARNI, suggesting a distinct role in HFrEF management.
Introduction:
Guideline-directed medical therapy (GDMT) has significantly improved outcomes in patients with heart failure with reduced ejection fraction (HFrEF). However, GDMT prescribing remains suboptimal. The purpose of this study was to survey cardiologists, internists, and pharmacists on their approach to GDMT prescribing.
Methods:
A survey containing 20 clinical vignettes of patients with HFrEF was answered by 127 cardiologists, 68 internists, and 89 pharmacists. Each vignette presented options for adjusting GDMT. Responses were dichotomized to the answer of interest. A mixed-effect model was used to calculate the odds of changing GDMT between pharmacists and physicians.
Results:
Pharmacists were more likely to make changes to GDMT compared with internists (92.1% vs 82%; odds ratio [OR] 3.02 [1.50-6.06]; p=0.002). In medically-naïve patients, pharmacists were more likely to initiate beta-blockers than internists (45.4% vs 32.0%; OR 2.19 [1.00-4.79], p=0.049). Pharmacists were more likely than both internists and cardiologists to initiate mineralocorticoid receptor antagonists (34.4% vs 11.5%; OR 4.95 [2.41-10.18]; p<0.001 and 34.4% vs 13.9%; OR 3.95 [2.16-7.21]; p<0.001). Pharmacists were more likely than both internists and cardiologists to titrate beta-blockers (30.9% vs 16.4%; OR 3.15 [1.92-5.19]; p<0.001 and 30.9% vs 22.0%; OR 1.88 [0.18-2.87]; p=0.0030). Pharmacists were more likely than internists to titrate angiotensin receptor-neprilysin inhibitors (ARNI) (61.8% vs 34.1%; OR 3.54 [1.50-8.39]; p=0.004).
Conclusions:
The survey results show pharmacists were more likely to make any adjustments to GDMT than internists and cardiologists. Pharmacists prefer adding spironolactone and titrating beta-blockers compared with cardiologists and internists. Compared with only internists, pharmacists were more likely to initiate beta-blockers and titrate the dose of ARNI.
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