Pharmacist intervention in primary care to improve outcomes in patients with left ventricular systolic dysfunction

Lowrie, Richard; Mair, Frances S; Greenlaw, Nicola; Forsyth, Paul; Jhund, Pardeep S.; McConnachie, Alex; Rae, Brian; McMurray, John J.V.

doi:10.1093/eurheartj/ehr433

Cited by 99 publications

(82 citation statements)

References 32 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%

“…There were favourable trends for beta-blocker titration, however these did not achieve statistical significance. 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.…”

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

View full text Add to dashboard Cite

show abstract

“…However, no difference in composite endpoint comprising death or hospitalisation due to worsening of HF symptoms was observed between the study and control groups despite covering large groups of patients, i.e. more than 1000 per group, and long follow-up of 4.7 years [23]. It is worth asking the question about the cost-effectiveness of pharmaceutical care.…”

Section: The Role Of the Pharmacist In The Treatment Of Cvdmentioning

confidence: 99%

“…Eventually, pharmaceutical intervention can effectively increase the level of compliance of pharmacotherapy with current guidelines -which by definition means optimising pharmacotherapy in accordance with the principles of evidence-based medicine [22]. Interesting in this context is the study conducted by Lowrie et al [23] in the setting of patients using drugs recommended by current guidelines. Despite this, the intervention of a pharmacist has brought improvement in compliance of pharmacotherapy.…”

Section: The Role Of the Pharmacist In The Treatment Of Cvdmentioning

confidence: 99%

The role of the pharmacist in the care of patients with cardiovascular diseases

et al. 2016

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“…1 There are also plans to address important safety issues in India through prospective monitoring programs.…”

mentioning

confidence: 99%

Health Services Evidence, the Message and the Audiences

Brien

2011

Pharmacy Practice and Res

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This extends beyond an individual prescriber and patient. Nurses, pharmacists, doctors and dentists should be adequately informed and have access to a clinical advisory service to ensure that the new medicine is used as safely as possible, and that unexpected problems can be recognised and reported promptly.The introduction of dabigatran into clinical practice also highlights the importance of prospective monitoring of new drugs in defined populations. The need to evaluate oral warfarin replacements in chronic conditions should justify the investment required for prospective monitoring of outcomes. There are important public health and economic issues in the new world of warfarin alternatives and we may not have made the best start. However, pharmacists will continue to have an important role in the pharmacovigilance of these drugs as we explore their benefits and implications for patient safety.

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Pharmacist intervention in primary care to improve outcomes in patients with left ventricular systolic dysfunction

Abstract: A low-intensity, pharmacist-led collaborative intervention in primary care resulted in modest improvements in prescribing of disease-modifying medications but did not improve clinical outcomes in a population that was relatively well treated at baseline.

Cited by 99 publications

References 32 publications

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

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

The role of the pharmacist in the care of patients with cardiovascular diseases

Health Services Evidence, the Message and the Audiences

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