Implementing Nonphysician Provider Guideline-Directed Medical Therapy Heart Failure Clinics: A Multi-National Imperative

Abstract

Heart failure (HF) is a global epidemic, with more than 60 million patients living with HF worldwide. 1 Lippi G Sanchis-Gomar F. Global epidemiology and future trends of heart failure. AME Med J. 2020; 5 Crossref Google Scholar With an ageing population, this number is projected to continue to increase and will result in significant economic and resource strain on health care systems. Despite recent advances in pharmacotherapy, morbidity and mortality related to HF remains high. This, in part, may be related to a significant portion of patients receiving sub-optimal, guideline-directed medical pharmacotherapy (GDMT). Greene et al 2 Greene SJ Butler J Albert NM et al. Medical therapy for heart failure with reduced ejection fraction: the champ-hf registry. J Am Coll Cardiol. 2018; 72: 351-366 Crossref PubMed Scopus (270) Google Scholar highlighted this trend in the United States through the Change the Management of Patients with Heart Failure (CHAMP-HF) registry. Among patients with HF with reduced ejection fraction (HFrEF) eligible for angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors (ARNi), beta blockers (BB), and mineralocorticoid receptor antagonists, these therapies were, concerningly, only prescribed in 27%, 33%, and 67% of eligible patients. Only a small portion of patients started on these foundational therapies were receiving target doses. Most notably, only 1% of the 3518 patients (approximately 35 patients) were simultaneously receiving target doses of all 3 therapies. The picture is similar internationally, with British registry data showing that failure to prescribe all 3 disease-modifying therapies is negatively associated with mortality in patients discharged after a recent HF hospitalization. It should also be mentioned that current registry data was collected before the release of recent sodium-glucose transport protein 2 inhibitor data, which has now led to an additional class of medications being recommended as part of the therapeutic backbone for HFrEF. 3 Maddox TM Januzzi JL et al. 2021 update to the 2017 acc expert consensus decision pathway for optimization of heart failure treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction: a report of the American College of Cardiology solution set oversight committee. J Am Coll Cardiol. 2021; 77: 772-810 Crossref PubMed Scopus (83) Google Scholar Furthermore, recent data from CONNECT-HF continues to reveal suboptimal dosing for patients with HFrEF, between 25% and 40% for ACEI, angiotensin receptor blocker, ARNI, BB, and mineralocorticoid receptor antagonist therapy. 4 CONNECT-HF: Can Additional HospitalPost-Discharge QI Interventions Improve HF Outcomes, Care?. American College of Cardiology, 2021https://www.acc.org/Latest-in-Cardiology/Articles/2021/05/12/19/40/Mon-8am-CONNECT-HF-acc-2021 Google Scholar