A Dedicated Guideline Directed Medical Therapy Clinic Improves Quality of Care and Outcomes In Patients with Heart Failure and Reduced Ejection Fraction

Abstract

Introduction Congestive heart failure is associated with significant morbidity and mortality. Based on the results of landmark trials, current guidelines recommend that patients with heart failure and reduced ejection fraction (HFrEF) be treated with a regimen of medications, referred to as guideline directed medical therapy (GDMT), at target doses. Unfortunately, recent studies have shown that GDMT at target doses is only achieved in 1% of eligible patients. Hypothesis Enrollment into a dedicated GDMT Clinic will increase the proportion of patients with HFrEF on GDMT at target doses and improve several heart failure parameters. Methods A prospective pilot cohort study was conducted enrolling 19 patients with HFrEF (EF ≤ 40%) into a GDMT Clinic. The proportion of patients on GDMT at target doses as well as heart failure parameters including ejection fraction (EF), LV end-diastolic diameter (LVIDd), 6 minute walk test (6MWT), Minnesota Living with Heart Failure Questionnaire (MLWHFQ) and PHQ-9 scores were compared at baseline and 3 months post intervention. Results The mean age of our cohort was 66.4 ± 8.6 years and the median duration of heart failure diagnosis was 15 months. 21% were female, 84% were Caucasian, 63% had non-ischemic cardiomyopathy, and 68% were NYHA class II. At baseline, 0% of eligible patients were on target doses of beta-blocker or ACEi/ARB/ARNI and 67% were on target doses of MRA. After enrolling in the GDMT Clinic, there was a substantial increase in the number of patients on target doses of beta-blocker (26%), ACEi/ARB/ARNI (26%) and MRA (89%). 11% of patients were simultaneously on target doses of all three drug classes. The number of patients on an ARNI increased by 58%. All patients were on maximally tolerated GDMT post intervention, with further up-titration limited by medication side effects. At 3 months post intervention, average EF significantly increased from 27.7 ± 7.3% to 34.8 ± 7.6% (p = 0.002). Mean LVIDd significantly decreased from 6.1 ± 0.8 cm to 5.7 ± 0.8 cm (p = 0.04). Median 6MWT results increased from 304.8 m [IQR: 240.4 - 404.6] to 318.4 m [IQR: 261.3 - 428.8] (p = 0.99). Median MLWHFQ scores improved from 15.5 [IQR: 5.0 - 44.5] to 11.5 [IQR: 3.5 - 23.5] (p = 0.79). Median PHQ-9 scores increased from 1.5 [IQR: 0.5 - 5.0] to 2.0 [IQR: 0.5 - 5.0] (p = 0.79). Conclusions Enrollment of patients with HFrEF into a dedicated GDMT Clinic is an effective strategy to increase the proportion of patients on target doses of GDMT and improve clinical outcomes.