Implementation of an Accelerated Treatment Pathway for Patients with Heart Failure With Reduced Ejection Fraction

Contemporary guideline-directed medical therapy for patients with heart failure with reduced ejection fraction (HFrEF) includes four classes of drugs with independent and additive benefits. While current guidelines recommend early initiation and rapid dose titration of quadruple therapy, its effective and safe implementation in real-world clinical practice remains uncertain.

A nurse-led clinical pathway was developed to support early in-hospital initiation of quadruple therapy and rapid post-discharge titration for patients admitted with HFrEF. The Accelerated Treatment (ACT) Pathway was introduced for patients admitted under the Cardiology Service at Te Toka Tumai Auckland Hospital, New Zealand. The pathway involves initiating low-dose quadruple therapy before discharge, followed by weekly clinic visits to facilitate individualised drug up-titration over a 4-week period. Follow-up echocardiography was performed after 3 months to re-assess left ventricular ejection fraction (LVEF) according to usual clinical practice. This report describes the early experience with the ACT Pathway, including drug use, safety outcomes, and changes in LVEF in response to treatment.

Between March 2023 and October 2024, 103 patients proceeded with the planned pathway. The mean age was 57 years, 20% were women, 67% were non-New Zealand European (including 17% Māori and 27% Pacific), 59% had non-ischaemic heart failure, and the median LVEF was 27%. At hospital discharge, quadruple therapy was successfully initiated, with all patients receiving renin-angiotensin-aldosterone system (RAAS) inhibitors, 96% beta blockers, 87% spironolactone, and 55% sodium-glucose cotransporter 2 inhibitors. The proportion of patients meeting the performance measure (≥50% of the maximum dosage) increased from discharge to 4 weeks as follows: RAAS inhibitors, 31%-82%; and beta blockers, 35%-69% (all p<0.001); and the proportion of patients receiving mineralocorticoid receptor antagonists increased from 87% to 92%. Loop diuretic use decreased: only 40% of patients were still receiving a daily dose of diuretic at 4 weeks. There were no hospital admissions due to hypotension or acute kidney injury. Median LVEF was 27% (interquartile range [IQR] 20-33) during hospitalisation and 43% (IQR 34-50) after 3 months, an overall increase of 13 percentage points (p<0.001).

The implementation of the ACT Pathway successfully achieved its goal of safe, early initiation and rapid titration of quadruple therapy to maximum tolerated doses within 4 weeks in patients admitted with HFrEF in a real-world setting. This pathway has demonstrated the potential for substantial benefits for patients, whānau, and the health care system in a New Zealand context.