Assessing Remote Optimization of Guideline-Directed Medical Therapy in HFrEF

Remote titration of guideline-directed medical therapy (GDMT) may be beneficial for the management of patients with heart failure with reduced ejection fraction, according to a study published in JAMA Cardiology.

The investigators contacted patients with chronic heart failure and left ventricular ejection fraction ≤40% who were receiving longitudinal cardiovascular follow-up care about participating in a remote medication optimization program. For patients whose clinicians granted permission, navigators and pharmacists adjusted medical therapy according to a sequential, stepped titration algorithm modeled according to heart failure guidelines by the American College of Cardiology and American Heart Association.

Participants were maintained under supervision of a nurse practitioner and heart failure cardiologist. Once patients reached the maximally tolerated or guideline-directed dose of each medication class, their care was returned to primary clinicians. Patients and clinicians who declined to participate were included in the control group.

The study included 1028 patients (mean values: age, 68±14 years; ejection fraction, 32±8%; and systolic blood pressure, 122±18 mm Hg; (30.0% women; and 86.8% in New York Heart Association class I and II).

The remote program included 197 patients (19.2%; mean age, 66±12.7 years; 29.9% women), and 831 participants (80.8%; mean age, 68±14.5 years; 29.6% women) continued with usual care.

At 3 months, participants in the remote program had significant increases compared with baseline levels in the use of renin-angiotensin system antagonists (baseline: 70.1%; 3 months, 86.3%; P <.001) and β-blockers (baseline: 77.2%’ 3 months: 91.9%; P <.001), but not in the use of mineralocorticoid receptor antagonists (baseline: 25.9%; 3 months: 30.5%; P =.14). Doses for each category of GDMT also increased from baseline in the intervention group. No changes were observed from baseline to 3 months in the percentage of patients receiving GDMT, or in the dose of GDMT in any category in the usual-care group.

“Remote drug titration was orchestrated with a low rate of adverse events without disruption of physician-patient relationships, with greater acceptance and efficacy among patients followed up by general cardiologists than in those followed up by heart failure specialists,” noted the researchers. “This approach may represent a scalable, population-level strategy to close the gap between guidelines and implementation of GDMT in clinical practice.”

Limitations to the study include its nonrandomized design and short follow-up duration, which may have biased the results in favor of the intervention group.

The study authors noted that remote management might also help expand access to specialty expertise in rural or underserved areas.

“In the context of a pandemic that has emphasized the vital importance of effective strategies for remote patient engagement, further study to assess the generalizability to community populations at scale seems warranted,” concluded the researchers.

Disclosures: Some of the authors declared affiliations with pharmaceutical companies. Please see the original reference for a full list of disclosures.

Reference

Desai AS, Maclean T, Blood AJ, et al. Remote optimization of guideline-directed medical therapy in patients with heart failure with reduced ejection fraction [published online September 16, 2020]. JAMA Cardiol. doi:10.1001/jamacardio.2020.3757