Ultra-fast remote up-titration of heart failure treatment: a safe, efficient and feasible protocol

Autor: M Massot, R Itier, M Galinier, J Roncalli, P Fournier, S Ayot, G Galtier
Rok vydání: 2022
Předmět:
Zdroj: European Heart Journal. 43
ISSN: 1522-9645
0195-668X
DOI: 10.1093/eurheartj/ehac544.945
Popis: Introduction Heart failure (HF) is a common disease with a significant economic burden, mainly caused by HF hospitalisations and significant morbi-mortality. Nevertheless, HF patients are still undertreated due to a clinical inertia that needs to be reversed as soon as possible using new, safe and available methods. Remote up-titrating HF medication might be the solution to rapidly optimize HF treatment to maximal tolerated doses. Purpose Our objective was to describe the safety, efficacy and feasibility of an ultra-fast remote up-titration protocol of HF treatment. Methods Patients with a recent hospitalization due to a HF decompensation and left ventricular ejection fraction Results We evaluated 96 patients, 25% female with a mean LVEF at 29%, main etiology of HF was ischemic (48%) and mean NTproBNP was 2384 pg/mL. Mean BP was 112/70 mmHg, HR was 73 bpm, glomerular filtration rate (GFR) 71 ml/min and potassium concentration was 4,4 mEq/L. Ninety four patients were initially treated with a beta blocker (BB), 29% of our cohort was treated either with an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB) and 59% was treated with angiotensin receptor neprilysin inhibitor (ARNI). A total of 72 patients were treated with a mineralocorticoid receptor antagonist (MRA) and 58 patients were also treated with an inhibitor of sodium-glucose transport protein 2 (SLGT2i), Figure 1. Median duration of tele-titration consultation was 42 days. We up-titrated BB in 50% of our patients, of which 10% were at maximum dose, making a total of 98% of our cohort under BB treatment. Sixty percent of patients under ACEI or ARB were switched to ARNI. Of the 82% of patients under ARNI, up to 50% achieved the maximal dose. We introduced or up-titrated ARM in 41 patients, reaching the target dose in 37%. Dose variations and mean initial and final doses are shown in Figure 2.1 and 2.2 Minor adverse events that motivated a down-titration or a cessation of treatment were, hyperkalemia 5%, acute renal failure (ARF) 6%, hypotension 3% and bradycardia 2%. Non urgent hospitalization due to ARF with hyperkalemia or HF only occurred in 2 cases. The limiting factors for not reaching the optimal targeted dose were low HR in 20%, hypotension in 11%, high concentration of potassium 10% and chronic renal failure in 9%. Conclusion Remote up-titration of HF medication is a promising tool in the fight against clinical inertia and a fast, feasible, safe (only 2% of major events) and efficient solution to our undertreated patients. Funding Acknowledgement Type of funding sources: None.
Databáze: OpenAIRE
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