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. 2020 Dec 1;5(12):1430-1434.
doi: 10.1001/jamacardio.2020.3757.

Remote Optimization of Guideline-Directed Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction

Akshay S Desai  1   2 , Taylor Maclean  1 , Alexander J Blood  1   2 , Joshua Bosque-Hamilton  1 , Jacqueline Dunning  1 , Christina Fischer  1 , Liliana Fera  1   2 , Katelyn V Smith  1 , Kavishwar Wagholikar  3 , David Zelle  1 , Thomas Gaziano  1   2 , Jorge Plutzky  1   2 , Benjamin Scirica  1   2 , Calum A MacRae  1   2
Affiliations

Remote Optimization of Guideline-Directed Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction

Akshay S Desai et al. JAMA Cardiol. .

Erratum in

  • Error in Supplement.
    [No authors listed] [No authors listed] JAMA Cardiol. 2021 Apr 1;6(4):485. doi: 10.1001/jamacardio.2021.0091. JAMA Cardiol. 2021. PMID: 33625470 Free PMC article. No abstract available.

Abstract

Importance: Optimal treatment of heart failure with reduced ejection fraction (HFrEF) is scripted by treatment guidelines, but many eligible patients do not receive guideline-directed medical therapy (GDMT) in clinical practice.

Objective: To determine whether a remote, algorithm-driven, navigator-administered medication optimization program could enhance implementation of GDMT in HFrEF.

Design, setting, and participants: In this case-control study, a population-based sample of patients with HFrEF was offered participation in a quality improvement program directed at GDMT optimization. Treating clinicians in a tertiary academic medical center who were caring for patients with heart failure and an ejection fraction of 40% or less (identified through an electronic health record-based search) were approached for permission to adjust medical therapy according to a sequential titration algorithm modeled on the current American College of Cardiology/American Heart Association heart failure guidelines. Navigators contacted participants by telephone to direct medication adjustment and conduct longitudinal surveillance of laboratory tests, blood pressure, and symptoms under supervision of a pharmacist, nurse practitioner, and heart failure cardiologist. Patients and clinicians declining to participate served as a control group.

Exposures: Navigator-led remote optimization of GDMT compared with usual care.

Main outcomes and measures: Proportion of patients receiving GDMT in the intervention and control groups at 3 months.

Results: Of 1028 eligible patients (mean [SD] values: age, 68 [14] years; ejection fraction, 32% [8%]; and systolic blood pressure, 122 [18] mm Hg; 305 women (30.0%); 892 individuals [86.8%] in New York Heart Association class I and II), 197 (19.2%) participated in the medication optimization program, and 831 (80.8%) continued with usual care as directed by their treating clinicians (585 [56.9%] general cardiologists; 443 [43.1%] heart failure specialists). At 3 months, patients participating in the remote intervention experienced significant increases from baseline in use of renin-angiotensin system antagonists (138 [70.1%] to 170 [86.3%]; P < .001) and β-blockers (152 [77.2%] to 181 [91.9%]; P < .001) but not mineralocorticoid receptor antagonists (51 [25.9%] to 60 [30.5%]; P = .14). Doses for each category of GDMT also increased from baseline in the intervention group. Among the usual-care group, there were no changes from baseline in the proportion of patients receiving GDMT or the dose of GDMT in any category.

Conclusions and relevance: Remote titration of GDMT by navigators using encoded algorithms may represent an efficient, population-level strategy for rapidly closing the gap between guidelines and clinical practice in patients with HFrEF.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Desai reports institutional research grants to the Brigham and Women’s Hospital from Abbott, Alnylam, AstraZeneca, Bayer, and Novartis, as well as consulting fees from Abbott, Alnylam, Amgen, AstraZeneca, Biofourmis, Boston Scientific, Boehringer Ingelheim, Corvidia Therapeutics, Cytokinetics, DalCor Pharma, Merck, Novartis, Relypsa, Regeneron, and Sun Pharma outside the submitted work. Ms Fischer is an employee of Philips and reported grants from Novartis Pharmaceutical Corporation during the conduct of the study. Dr Gaziano reports research grants from the US National Institutes of Health, Novartis, and United HealthCare outside the submitted work and Blue Cross Blue Shield of Massachusetts during the conduct of the study and has been a consultant to Amgen, AstraZeneca, Teva, and Takeda. Dr Plutzky reported an institutional research grant to the Brigham and Women’s Hospital from Boehringer Ingelheim and consulting fees from Amgen, Esperion, Novo Nordisk, Sanofi, Regeneron, and Vivus. Dr Scirica reported grants from Novartis during the conduct of the study; institutional research grants to the Brigham and Women’s Hospital from AstraZeneca, Eisai, Merck, Novartis, and Pfizer outside the submitted work; an additional grant from Novo Nordisk; consulting fees from AbbVie, Allergan, Boehringer Ingelheim, Covance, Eisai, Esperion, Elsevier Practice Update Cardiology, GlaxoSmithKline, Hamni, Lexicon, Medtronic, Merck, Novo Nordisk, and Health at Scale outside the submitted work; and equity in Health at Scale. Dr Scirica is a member of the TIMI Study Group, which has received institutional research grant support through Brigham and Women's Hospital from Abbott, Amgen, Aralez, AstraZeneca, Bayer HealthCare Pharmaceuticals Inc, BRAHMS, Daiichi-Sankyo, Eisai, GlaxoSmithKline, Intarcia, Janssen, MedImmune, Merck, Novartis, Pfizer, Poxel, Quark Pharmaceuticals, Roche, Takeda, the Medicines Company, and Zora Biosciences. Dr MacRae reports research funding from the American Heart Association, Verily Life Sciences, AstraZeneca, Quest Diagnostics, Merck, Sanofi and Novartis, is a consultant to AstraZeneca, Pfizer, Foresite Labs and Clarify Health Solutions and is a cofounder of Atman Health. Dr MacLean reported grants from Novartis during the conduct of the study. Dr Blood reported grants from Novartis during the conduct of the study; in addition, Dr Blood had a patent on Digital Medical Image Data Sharing and Team Activation issued. Dr MacRae reported grants from Novartis during the conduct of the study; grants from American Heart Association, Verily, Quest Diagnostics, and Apple and other support from Bodyport and Atman Health outside the submitted work. In addition, Dr MacRae had a patent for tools for the algorithmic management of care issued. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Change From Baseline in Use of Guideline-Directed Medical Therapy (GDMT) by Drug Category and Study Group
ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blockers; ARNI, angiotensin receptor–neprilysin inhibitor; MRA, mineralocorticoid receptor antagonist.
Figure 2.
Figure 2.. Dosing of Guideline-Directed Medical Therapy (GDMT) at 3 Months, by Treatment Group
Colors indicate dosage as a percentage of guideline-directed targets for each medication category at each point. Statistical comparisons reflect the different proportions in those receiving 50% or more of target dose in each group. ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor neprilysin inhibitor; MRA, mineralocorticoid receptor antagonist.
See this image and copyright information in PMC

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