Titrating Heart Failure Therapies: Pick Up the Phone, Follow the Script

Physician-supervised clinical staff helped improve uptake of guideline-directed medical therapy (GDMT) by calling heart failure patients and following a medication titration algorithm, one center found.

Implementation of the intervention was associated with increased use of some medications for heart failure with reduced ejection fraction (HFrEF) at 3 months:

• Renin-angiotensin-aldosterone system (RAAS) inhibitors: from 70.1% to 86.3% (P<0.001)
• Beta-blockers: 77.2% to 91.9% (P<0.001)
• Mineralocorticoid receptor antagonists (MRAs): 25.9% to 30.5%, albeit not statistically significant at P=0.14

Doses of each category of GDMT increased from baseline following the intervention, according to researchers led by Akshay Desai, MD, MPH, of Brigham and Women’s Hospital in Boston, reporting online in JAMA Cardiology.

On the other hand, HFrEF patients who opted not to participate in the institutional quality improvement initiative showed no significant increase from baseline in their use or dosage of any GDMT (e.g., RAAS inhibitor use stayed around 70%, beta-blockers 85%, and MRAs 30%).

As for safety events, there was more worsening kidney function (rise in serum creatinine to >0.3 mg/dL) among the intervention group when compared with controls (9.1% vs 0.4%, P<0.001).

“Our data suggest that many of the barriers to use of GDMT in clinical practice might be overcome at scale by engaging nonphysician personnel to supplement clinic-based follow-up and support the process of pharmacologic optimization,” according to Desai and colleagues.

The intervention involved patient navigators and pharmacists calling patients to direct medication adjustment (following an algorithm modeled on current heart failure guidelines) and conduct longitudinal surveillance of laboratory tests, blood pressure, and symptoms under supervision of a nurse practitioner and heart failure cardiologist.

The 197 patients from Desai’s institution who opted to participate in the intervention received an average of 8.6 calls over 140.6 days. Mean age was 68 years, and ejection fraction 32%. Women accounted for 30% of the group. Roughly seven out of eight people were in New York Heart Association class I and II.

Controls were 831 HFrEF patients who chose usual care instead. The two arms of the case-control study had marked baseline differences.

“Patients with more advanced disease followed up by HF specialists had higher use of GDMT at baseline and were more likely than those followed up by general cardiologists to opt out of the remote titration approach, but were less likely to benefit from the intervention,” the investigators noted.

A lack of significantly improved MRA uptake at 3 months may be “a consequence of the strict criteria used to assess MRA eligibility in this population, which had predominantly New York Heart Association I and II-level disease,” the investigators reasoned.

Desai’s group acknowledged the non-randomized nature and short follow-up of the study, along with other limitations.

“Remote titration of GDMT by navigators using encoded algorithms may represent an efficient, population-level strategy for rapidly closing the gap between guidelines and clinical practice in patients with HFrEF,” study authors wrote.

Remote HF management has the potential benefit of increasing access to specialty expertise, particularly for people in rural or underserved areas.

“In the context of a pandemic that has emphasized the vital importance of effective strategies for remote patient engagement, further study to assess the generalizability to community populations at scale seems warranted,” according to Desai and colleagues.