Implementation of a pharmacist-managed heart failure medication titration clinic

Martinez, Amanda; Saef, Jerold; Paszczuk, Anna; Bhatt-Chugani, Hetal

doi:10.2146/ajhp120267

Cited by 53 publications

(63 citation statements)

References 21 publications

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“…47 Studies have also evaluated pharmacist-managed medication titration in HF. 37,38 Recognising the key role that general practitioners (GPs) play in HF management, Lowrie et al undertook a cluster-RCT of nonspecialist, pharmacist-managed medication titration in 1,090 HFrEF patients attending 87 practices in United Kingdom. While this study did not achieve its primary clinical endpoint, a higher proportion of patients who enrolled in practices with pharmacist-assisted titration achieved target doses of ACEI therapy.…”

Section: Medication Titration Intervention Studiesmentioning

confidence: 99%

“…38 In a before-after, retrospective design study targeting 51 higher-risk HFrEF patients conducted in the United States, Martinez et al demonstrated that a multifaceted intervention, which included pharmacist-managed titration guided by telephone monitoring, resulted in a higher proportion of patients achieving target doses of ACEI/ARB and beta-blockers. 37 We recently undertook a quality improvement study that aimed to embed a pre-designed medication titration plan into standard clinical practice for patients newly referred to the HF services in three hospitals. 48 This study involved completing and faxing a customised medication titration form to the patient's GP on the day of hospital discharge that clearly defined which healthcare provider was primarily responsible for medication titration.…”

Section: Medication Titration Intervention Studiesmentioning

confidence: 99%

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Expert Comment: Is Medication Titration in Heart Failure too Complex?

Atherton¹,

Hickey²

2017

Cardiac Failure Review

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The prevalence of heart failure (HF) continues to rise, driven by an ageing population, increasing rates of obesity and diabetes, and better survival in patients with cardiovascular disease.1 While HF is associated with substantial morbidity and mortality, a number of treatments have been shown to improve outcomes in large-scale randomised controlled trials (RCT), including pharmacological inhibition of the renin-angiotensin system (with or without neprilysin inhibition), betablockers, mineralocorticoid receptor antagonists, sinus node inhibition, cardiac resynchronisation therapy with biventricular pacing, implantable cardioverter defibrillators and multidisciplinary models of care. [2][3][4] In order to realise the benefits of these treatments, however, we need to consider how patients were selected for these RCT and how the treatments were delivered.The adoption of innovative models of care and the delivery of device therapies can be particularly challenging, given that they are highly dependent on the individual operators and rely on substantial infrastructure and staffing support. At first glance, it would appear that the administration of pharmacological therapies for HF should be relatively straightforward, but such therapies are also highly dependent on the individual prescribers, rely on substantial infrastructure and staffing support, and involve real complexities around medication persistence and patient adherence.In this review, we will discuss medication titration in HF and consider whether or not it is too complex in the real-world setting.We conducted a literature search in November and December 2016 using PubMed. Keywords included 'heart failure', which was used in combination with 'medication' or 'therapy' and 'titration' or 'up-titration', 'dose' or 'target dose'. We also searched reference lists of relevant primary studies and systematic reviews. We used no language or date restrictions. All types of study design were included where medication titration was a primary endpoint. Clinical Trials Evaluating Medications in Heart FailureLarge-scale randomised controlled trials (RCTs) have demonstrated that angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), beta-blockers and mineralocorticoid receptor antagonists all improve clinical outcomes in patients with HF associated with a reduced left ventricular ejection fraction (HFrEF). 5-12Indeed, such studies suggest that the combination of an ACEI, betablocker and mineralocorticoid receptor antagonist should translate to a 60-70 % relative risk reduction in all-cause mortality. 13 Nevertheless, it is likely that the balance between benefit and harm varies according to patient age, disease severity, associated comorbidities and approaches to monitoring and medication titration. An example of the impact of comorbidities was demonstrated by an individual patient data meta-analysis of the beta-blocker RCTs, in which the benefits were only observed in patients in sinus rhythm, there was no reduction in hospitalisation or...

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Section: Medication Titration Intervention Studiesmentioning

confidence: 99%

Section: Medication Titration Intervention Studiesmentioning

confidence: 99%

Expert Comment: Is Medication Titration in Heart Failure too Complex?

Atherton¹,

Hickey²

2017

Cardiac Failure Review

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“…(9) Heart failure disease management (HFDM) programs improve outcomes in patients recently discharged from hospital, helping to provide a "bridge" between hospital and primary care. (14) Specialized HF medical clinics or protocol-driven nurse and pharmacist led clinics can be effective in improving titration following hospitalization (15)(16)(17)(18) although this finding has not been universal. (6) HFDM services may help to address barriers by providing access to specialized multidisciplinary staff familiar with current guidelines, who have the time and skills to support medication monitoring.…”

Section: Accepted M Manuscriptmentioning

confidence: 99%

Improving medication titration in heart failure by embedding a structured medication titration plan

Hickey

Suna

Marquart

et al. 2016

International Journal of Cardiology

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ing medication titration in heart failure by embedding a structured medication titration plan, International Journal of Cardiology (2016Cardiology ( ), doi: 10.1016Cardiology ( /j.ijcard.2016 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. A C C E P T E D M A N U S C R I P T ACCEPTED MANUSCRIPT A C C E P T E D M A N U S C R I P T ACCEPTED MANUSCRIPT ABSTRACTBackground: To improve up-titration of medications to target dose in heart failure patients by

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“…23 Although these trials in hypertension were in the setting of the prevention of heart disease as opposed to the therapy for HF, the principles of organized or protocol-driven patient review with stepped pharmacotherapy using the assistance of nurses and pharmacists has a direct application to the titration of HF pharmacotherapy. Pharmacist-led titration has been shown to increase the percentage of patients receiving optimal HF drug dosing, 24 and nurse-led phone-based intervention may increase both the proportion of patients achieving the trial-defined optimal dose and may improve left ventricular ejection fraction and reduce the need for device therapy in HF. 25 Diabetes Diabetes is present in more than one-third of Medicare recipients with HF.…”

Section: Hypertensionmentioning

confidence: 99%

Team-Based Care for Managing Noncardiac Conditions in Patients with Heart Failure

Vader

Rich

2015

Heart Failure Clinics

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Implementation of a pharmacist-managed heart failure medication titration clinic

Abstract: Implementation of a pharmacist-managed HF medication titration clinic increased the percentage of patients achieving optimal ACEI, ARB, and β-blocker dosages.

Cited by 53 publications

References 21 publications

Expert Comment: Is Medication Titration in Heart Failure too Complex?

Expert Comment: Is Medication Titration in Heart Failure too Complex?

Improving medication titration in heart failure by embedding a structured medication titration plan

Team-Based Care for Managing Noncardiac Conditions in Patients with Heart Failure

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