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, beta-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.
Virtual optimization of guideline-directed medical therapy in hospitalized patients with heart failure with reduced ejection fraction: the IMPLEMENT-HF pilot study.
Authors: Bhatt, Ankeet S; Varshney, Anubodh S; Nekoui, Mahan; Moscone, Alea; Cunningham, Jonathan W; Jering, Karola S; Patel, Parth N; Sinnenberg, Lauren E; Bernier, Thomas D; Buckley, Leo F; Cook, Bryan M; Dempsey, Jillian; Kelly, Julie; Knowles, Danielle M; Lupi, Kenneth; Malloy, Rhynn; Matta, Lina S; Rhoten, Megan N; Sharma, Krishan; Snyder, Caroline A; Ting, Clara; McElrath, Erin E; Amato, Mary G; Alobaidly, Maryam; Ulbricht, Catherine E; Choudhry, Niteesh K; Adler, Dale S; Vaduganathan, Muthiah
Eur J Heart Fail. 2021 Jul;23(7):1191-1201. doi: 10.1002/ejhf.2163. Epub 2021 Apr 13.