Open AccessRationale and design of a navigator‐driven remote optimization of guideline‐directed medical therapy in patients with heart failure with reduced ejection fraction
Author(s) -
Blood Alexander J.,
Fischer Christina M.,
Fera Liliana E.,
MacLean Taylor E.,
Smith Katelyn V.,
Dunning Jacqueline R.,
BosqueHamilton Joshua W.,
Aronson Samuel J.,
Gaziano Thomas A.,
MacRae Calum A.,
Matta Lina S.,
MercurioPinto Ana A.,
Murphy Shawn N.,
Scirica Benjamin M.,
Wagholikar Kavishwar,
Desai Akshay S.
Publication year - 2020
Publication title -
clinical cardiology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.263
H-Index - 72
eISSN - 1932-8737
pISSN - 0160-9289
DOI - 10.1002/clc.23291
Subject(s) - medicine , ejection fraction , heart failure , informed consent , cardiac resynchronization therapy , population , destination therapy , guideline , ventricular assist device , transplantation , heart transplantation , pharmacist , canadian cardiovascular society , emergency medicine , intensive care medicine , cardiology , family medicine , pharmacy , alternative medicine , environmental health , pathology , myocardial infarction , angina
Although optimal pharmacological therapy for heart failure with reduced ejection fraction (HFrEF) is carefully scripted by treatment guidelines, many eligible patients are not treated with guideline‐directed medical therapy (GDMT) in clinical practice. We designed a strategy for remote optimization of GDMT on a population scale in patients with HFrEF leveraging nonphysician providers. An electronic health record‐based algorithm was used to identify a cohort of patients with a diagnosis of heart failure (HF) and ejection fraction (EF) ≤ 40% receiving longitudinal follow‐up at our center. Those with end‐stage HF requiring inotropic support, mechanical circulatory support, or transplantation and those enrolled in hospice or palliative care were excluded. Treating providers were approached for consent to adjust medical therapy according to a sequential, stepped titration algorithm modeled on the current American College of Cardiology (ACC)/American Heart Association (AHA) HF Guidelines within a collaborative care agreement. The program was approved by the institutional review board at Brigham and Women's Hospital with a waiver of written informed consent. All patients provided verbal consent to participate. A navigator then facilitated medication adjustments by telephone and conducted longitudinal surveillance of laboratories, blood pressure, and symptoms. Each titration step was reviewed by a pharmacist with supervision as needed from a nurse practitioner and HF cardiologist. Patients were discharged from the program to their primary cardiologist after achievement of an optimal or maximally tolerated regimen. A navigator‐led remote management strategy for optimization of GDMT may represent a scalable population‐level strategy for closing the gap between guidelines and clinical practice in patients with HFrEF.