Abstract
ObjectiveRecent studies have reported suboptimal up-titration of heart failure (HF) therapies in patients with heart failure and a reduced ejection fraction (HFrEF). Here, we report on the achieved doses after nurse-led up-titration, reasons for not achieving the target dose, subsequent changes in left ventricular ejection fraction (LVEF), and mortality.MethodsFrom 2012 to 2018, 378 HFrEF patients with a recent (< 3 months) diagnosis of HF were referred to a specialised HF-nurse led clinic for protocolised up-titration of guideline-directed medical therapy (GDMT). The achieved doses of GDMT at 9 months were recorded, as well as reasons for not achieving the optimal dose in all patients. Echocardiography was performed at baseline and after up-titration in 278 patients.ResultsOf 345 HFrEF patients with a follow-up visit after 9 months, 69% reached ≥ 50% of the recommended dose of renin-angiotensin-system (RAS) inhibitors, 73% reached ≥ 50% of the recommended dose of beta-blockers and 77% reached ≥ 50% of the recommended dose of mineralocorticoid receptor antagonists. The main reasons for not reaching the target dose were hypotension (RAS inhibitors and beta-blockers), bradycardia (beta-blockers) and renal dysfunction (RAS inhibitors). During a median follow-up of 9 months, mean LVEF increased from 27.6% at baseline to 38.8% at follow-up. Each 5% increase in LVEF was associated with an adjusted hazard ratio of 0.84 (0.75–0.94, p = 0.002) for mortality and 0.85 (0.78–0.94, p = 0.001) for the combined endpoint of mortality and/or HF hospitalisation after a mean follow-up of 3.3 years.ConclusionsThis study shows that protocolised up-titration in a nurse-led HF clinic leads to high doses of GDMT and improvement of LVEF in patients with new-onset HFrEF.Supplementary InformationThe online version of this article (10.1007/s12471-021-01591-6) contains supplementary material, which is available to authorized users.
Highlights
Heart failure (HF) is considered a chronic and often progressive disease
This study reports on the changes in left ventricular ejection fraction (LVEF) in the setting of a protocolised up-titration in a specialised nurse-led heart failure (HF) clinic
This study shows that high doses of guideline-directed medical therapy (GDMT) and improvement of LVEF can be achieved in specialised nurse-led HF clinics using a guidelinebased up-titration protocol
Summary
Heart failure (HF) is considered a chronic and often progressive disease. In the years following the diagnosis of HF a substantial proportion of patients develop left ventricular remodelling, which over time becomes maladaptive, and is characterised by increased dimensions of the left ventricle, thinner walls and decreased left ventricular ejection fraction (LVEF) [1]. Reverse remodelling (marked by a reduction of LV dimensions and improvement in LVEF) can be achieved in selected patients [2]. In a recent study of 1160 patients with heart failure with reduced ejection fraction (HFrEF), LVEF showed a marked rise during the first year, followed by a relatively long plateau phase of up to a decade and a subsequent slow decline [3]. In clinical trials and registries, a large majority of patients with HFrEF (80–90%) receive beta-blockers and/or angiotensin-converting-enzyme inhibitors/ angiotensin receptor blockers (ACEIs/ARBs) (at any dose). In the CHAMP-HF registry of 2588 outpatients with HFrEF from the United States, the percentage of those receiving target doses of mineralocorticoid receptor antagonists (MRAs), beta-blockers, ACEIs/ARBs or angiotensin receptor-neprilysin inhibitor (ARNIs) after 12 months of follow-up was 27%, 22%, 10% and 3% respectively [5]. In the cross-sectional CHECK-HF registry of 34 HF outpatient clinics in the Netherlands, median achieved drug doses were 50% of the target dose for renin-angiotensin-system (RAS) inhibitors, 25% of the target dose for betablockers, and 25% of the target dose for MRAs [6]
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