Examining the real-world up-titration of heart failure therapy and treatment related factors limiting optimisation in Irish nurse-led heart failure clinics

Abstract

Abstract Introduction The potential of guideline-directed heart failure therapy to reduce mortality and morbidity in HF patients is tremendous however real-world data indicates sub-optimal up-titration to target doses. Challenges to optimisation include patient-related factors, treatment related factors and service-related factors. The observational QUALIFY Study reported a prescription rate of 87.8% for ACEI's/ARB's, 86.9% for Beta-blockers and 70.3% for MRA's. Purpose To examine the real-world pattern of up-titration and maximisation of four pillars of HF therapy to maximum doses in Irish Nurse-led HF Clinics in comparison to recent observational/registry studies and to highlight the main treatment related factors limiting optimisation. Methods A cross sectional prospective audit over a 3-month period was carried out in 18 HF centres in Ireland. Ethical approval was sought and granted in all centres. Patients included in the audit were those with HFrEF that achieved optimal tolerated dose of betablocker, ARNI/ACE-I, MRA and SGLT2I during the period of the audit. Results The audit included 648 participants, 499 (77%) male and 147 (23%) female (2 unknown). Average age of male was 68.5 years old and female was 68.7 years old. The rate of prescription for ARNI and ACEi/ARB was 93.8% (n=608), 65% (n=420) of patients were prescribed ARNI, ACEi were prescribed for 147 (22.6%) and ARB’s for 41 (6.3%) patients respectively. Hypotension was a limiting factor in 22.4% (n=146) of cases. Over 608 (93.6%) patients received a beta-blocker to maximum tolerated dose and 6% (n=40) did not receive a beta-blocker. Hypotension was a limiting factor for 77 (11.8%) patients, followed by fatigue in 15 (2.3%) of patients. 84% of patients received an MRA and 97 (14.9%) patients did not received an MRA. Hyperkalaemia was a limiting factor in 51 cases (7.8%), followed by chronic kidney disease in 32 cases (4.9%) and hyponatraemia in 6 cases (0.9%). Only 13.2% (n=86) of patients did not receive an SGLT2 and 86.8% were prescribed an SGLT2. Urinary tract infection was reported in 13 cases (2%), CKD preluded prescription in 7 patients (1%) and fungal infection occurred in 3 cases (0.4%). Conclusion A strong commitment to optimising heart failure therapy is evident in Irish nurse-led clinics. Prescription rates for patients optimised were 93.8% for ARNI/ACE/ARB, 93.6% for BB, 84% for MRA and 86.8% for SGLT2. This has surpassed target doses seen in observation studies. Future audits will examine the impact of nurse prescribing on the achievement of optimal target doses.