Virtual optimization of guideline-directed medical therapy in hospitalized patients with heart failure with reduced ejection fraction: the IMPLEMENT-HF pilot study.

Autor: Bhatt AS; Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA., Varshney AS; Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA., Nekoui M; Harvard Medical School, Boston, MA, USA., Moscone A; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA., Cunningham JW; Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA., Jering KS; Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA., Patel PN; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA., Sinnenberg LE; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA., Bernier TD; Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA., Buckley LF; Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA., Cook BM; Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA., Dempsey J; Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA., Kelly J; Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA., Knowles DM; Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA., Lupi K; Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA., Malloy R; Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA., Matta LS; Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA., Rhoten MN; Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA., Sharma K; Department of Medicine, Massachusetts General Hospital, Boston, MA, USA., Snyder CA; Brown University, Providence, RI, USA., Ting C; Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA., McElrath EE; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA., Amato MG; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.; Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA., Alobaidly M; Department of Quality and Safety, Brigham and Women's Hospital, Boston, MA, USA., Ulbricht CE; Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA.; Department of Quality and Safety, Brigham and Women's Hospital, Boston, MA, USA., Choudhry NK; Center for Healthcare Delivery Sciences, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA., Adler DS; Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA., Vaduganathan M; Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
Jazyk: angličtina
Zdroj: European journal of heart failure [Eur J Heart Fail] 2021 Jul; Vol. 23 (7), pp. 1191-1201. Date of Electronic Publication: 2021 Apr 13.
DOI: 10.1002/ejhf.2163
Abstrakt: Aims: Implementation of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) remains incomplete. Non-cardiovascular hospitalization may present opportunities for GDMT optimization. We assessed the efficacy and durability of a virtual, multidisciplinary 'GDMT Team' on medical therapy prescription for HFrEF.
Methods and Results: Consecutive hospitalizations in patients with HFrEF (ejection fraction ≤40%) were prospectively identified from 3 February to 1 March 2020 (usual care group) and 2 March to 28 August 2020 (intervention group). Patients with critical illness, de novo heart failure, and systolic blood pressure <90 mmHg in the preceeding 24 hs prior to enrollment were excluded. In the intervention group, a pharmacist-physician GDMT Team provided optimization suggestions to treating teams based on an evidence-based algorithm. The primary outcome was a GDMT optimization score, the sum of positive (+1 for new initiations or up-titrations) and negative therapeutic changes (-1 for discontinuations or down-titrations) at hospital discharge. Serious in-hospital safety events were assessed. Among 278 consecutive encounters with HFrEF, 118 met eligibility criteria; 29 (25%) received usual care and 89 (75%) received the GDMT Team intervention. Among usual care encounters, there were no changes in GDMT prescription during hospitalization. In the intervention group, β-blocker (72% to 88%; P = 0.01), angiotensin receptor-neprilysin inhibitor (6% to 17%; P = 0.03), mineralocorticoid receptor antagonist (16% to 29%; P = 0.05), and triple therapy (9% to 26%; P < 0.01) prescriptions increased during hospitalization. After adjustment for clinically relevant covariates, the GDMT Team was associated with an increase in GDMT optimization score (+0.58; 95% confidence interval +0.09 to +1.07; P = 0.02). There were no serious in-hospital adverse events.
Conclusions: Non-cardiovascular hospitalizations are a potentially safe and effective setting for GDMT optimization. A virtual GDMT Team was associated with improved heart failure therapeutic optimization. This implementation strategy warrants testing in a prospective randomized controlled trial.
(© 2021 European Society of Cardiology.)
Databáze: MEDLINE
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