Nurse and general practioner-led up-titration strategy: a real world experience in a heart failure unit in colombia

Abstract

Funding Acknowledgements Type of funding sources: None. Background Despite improvement of heart failure (HF) prescription rates, doses prescribed in clinical practice are lower than those achieved in randomized clinical trials. Nurse-led up-titration strategy has been widely used in Europe with promising results. Nevertheless, there is no evidence of this approach in Latin America. Methods A prospective cohort study was conducted in 50 patients with reduced ejection fraction to evaluate efficacy and safety of nurse and general practioner(GP)-led up-titration protocol, based on problem solving from the European Society of Cardiology HF guidelines. Patients were admitted in our HF unit from January 2017 to December 2019. After discharge our clinical pathway provides 3 types of visits : Cardiologist visits, educational visits and titration visits with GP and registered nurse. Along intervention the registered nurse lead flexible diuretic titration and structured phone monitoring calls. Results Baseline characteristics are showed in Table 1. Mean age was 72.5 years, 50% of patients were women, 66% had ischemic cardiomiopathy, mean N-terminal pro-B-type natiuretic peptide was 3285pg/dl, and 58% of patients were NYHA class III. At 97 days with an average of 4 up-titration visits disease-modifying drugs titration was completed. At the beginning 98% of patients had Beta Blockers (BB) , 98% had Mineralocorticoid Receptor Antagonist (MRA), and all of them had Angiotensin Converting Enzyme Inhibitors, angiotensin receptor blockers or Angiotensin Receptor Neprilysin Inhibitor (ARNI). According to the guidelines Angiotensin Converting Enzyme Inhibitors and angiotensin receptor blockers were replaced by ARNI in symptomatic patients. At the end of titration, BB target dose was achieved for 44% of patients, intermediate dose for 46% and final low dose for only 10% of patients. Ivabradine was added for 22% of patients. MRA intermediate and high doses were achieved for 82,5% of patients. Target dose of ARNI was achieved for 62% of patients, intermediate dose for 22% and only 20% of patients remained in starting dose. On average ARNI target dose was completed at 56 days. According to our protocol three patients stopped MRA due to hyperkalemia and symptomatic hypotension was the main cause for stopping up-titration. There was a relationship between patient´s caregiver and higher doses of ARNI( p=0.624) and BB (p=0.421). Conclusion A nurse and GP directed up-titration protocol is an encouraging strategy in HF units to achieve the recommended doses of disease-modifying drugs according to the guidelines.