Meeting NewsPerspective

Remote titration of HF medications may increase utilization

Akshay S. Desai

PHILADELPHIA — Patients with HF with reduced ejection fraction who underwent remote titration of guideline-directed medical therapies by navigators showed an increase in the utilization of these drugs during a 3-month period compared with patients treated with usual care, according to data presented at the American Heart Association Scientific Sessions.

Researchers analyzed data from 1,028 patients (mean age, 68 years; 30% women) with HF and an ejection fraction less than 40%. Treating providers of these patients were contacted with regard to consent to adjust medical therapy. Providers and patients who declined to participate in this study were considered the reference group (n = 831). Patients in the treatment group (n = 197) were contacted by a navigator who assisted in adjusting medication through surveillance of BP, laboratories and symptoms with the help of a nurse practitioner, pharmacist and an HF cardiologist.

“The actual intervention in the remote arm was based on a detailed algorithm that we designed for sequential adjustment of guideline-directed medical therapy modeled on the ACC/AHA guidelines for titration of [medications] and introduction over time to target doses,” Akshay S. Desai, MD, MPH, associate professor of medicine at Harvard Medical School and medical director of the cardiomyopathy and heart failure program, advanced heart disease section, Brigham and Women’s Hospital, said during the presentation. “This was embedded within a software tool that was then used to provide patient-specific recommendations while paying mind to blood pressure, heart rate, renal function, potassium and other inputs.”

The primary outcome was the proportion of patients who received guideline-directed medical therapy in both the intervention and reference groups at 3 months.

At baseline, 73% of patients were treated with guideline-directed beta-blockers, 73.8% were treated with ACE inhibitors or angiotensin receptor-neprilysin inhibitors and 29% were receiving mineralocorticoid receptor antagonists. In addition, 11% of patients were treated with target doses of beta-blockers and 10% received the target dose of ACE inhibitors, angiotensin II receptor antagonists or angiotensin receptor-neprilysin inhibitors.

Compared with the reference group, patients who underwent treatment had greater increases from baseline to 3 months in the utilization of the following guideline-directed medical therapy:

ACE inhibitors, angiotensin II receptor antagonists or angiotensin receptor-neprilysin inhibitors (70.1% to 86.3% for the treatment group; P < .001; 72.6% to 74.4% for the reference group; P = .24);

beta-blockers (77.2% to 91.9% for the treatment group; P < .001; 84.5% to 86.3% for the reference group; P = .15); and

mineralocorticoid receptor antagonists (25.9% to 30.5% for the treatment group; P = .14; 28.9% to 30.3% for the reference group; P = .37).

“This approach may represent a scalable population-level strategy to close the gap between guidelines and implementation of [guideline-directed medical therapy] in clinical practice,” Desai said during the presentation. – by Darlene Dobkowski

Reference:

Desai AS, et al. Outpatient Strategies for Heart Failure Management. Presented at: American Heart Association Scientific Sessions; Nov. 16-18, 2019; Philadelphia.

Disclosures: The project was funded by an unrestricted grant from Novartis. Desai reports he received honoraria from Alnylam, AstraZeneca, Abbott, Biofourmis, Boehringer Ingelheim, Boston Scientific, DalCor, Novartis, Relypsa and Regeneron and other research support from Alnylam, AstraZeneca, Novartis. Please see the abstract for all other authors’ relevant financial disclosures.

Akshay S. Desai

PHILADELPHIA — Patients with HF with reduced ejection fraction who underwent remote titration of guideline-directed medical therapies by navigators showed an increase in the utilization of these drugs during a 3-month period compared with patients treated with usual care, according to data presented at the American Heart Association Scientific Sessions.

Researchers analyzed data from 1,028 patients (mean age, 68 years; 30% women) with HF and an ejection fraction less than 40%. Treating providers of these patients were contacted with regard to consent to adjust medical therapy. Providers and patients who declined to participate in this study were considered the reference group (n = 831). Patients in the treatment group (n = 197) were contacted by a navigator who assisted in adjusting medication through surveillance of BP, laboratories and symptoms with the help of a nurse practitioner, pharmacist and an HF cardiologist.

“The actual intervention in the remote arm was based on a detailed algorithm that we designed for sequential adjustment of guideline-directed medical therapy modeled on the ACC/AHA guidelines for titration of [medications] and introduction over time to target doses,” Akshay S. Desai, MD, MPH, associate professor of medicine at Harvard Medical School and medical director of the cardiomyopathy and heart failure program, advanced heart disease section, Brigham and Women’s Hospital, said during the presentation. “This was embedded within a software tool that was then used to provide patient-specific recommendations while paying mind to blood pressure, heart rate, renal function, potassium and other inputs.”

The primary outcome was the proportion of patients who received guideline-directed medical therapy in both the intervention and reference groups at 3 months.

At baseline, 73% of patients were treated with guideline-directed beta-blockers, 73.8% were treated with ACE inhibitors or angiotensin receptor-neprilysin inhibitors and 29% were receiving mineralocorticoid receptor antagonists. In addition, 11% of patients were treated with target doses of beta-blockers and 10% received the target dose of ACE inhibitors, angiotensin II receptor antagonists or angiotensin receptor-neprilysin inhibitors.

Compared with the reference group, patients who underwent treatment had greater increases from baseline to 3 months in the utilization of the following guideline-directed medical therapy:

ACE inhibitors, angiotensin II receptor antagonists or angiotensin receptor-neprilysin inhibitors (70.1% to 86.3% for the treatment group; P < .001; 72.6% to 74.4% for the reference group; P = .24);

beta-blockers (77.2% to 91.9% for the treatment group; P < .001; 84.5% to 86.3% for the reference group; P = .15); and

mineralocorticoid receptor antagonists (25.9% to 30.5% for the treatment group; P = .14; 28.9% to 30.3% for the reference group; P = .37).

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“This approach may represent a scalable population-level strategy to close the gap between guidelines and implementation of [guideline-directed medical therapy] in clinical practice,” Desai said during the presentation. – by Darlene Dobkowski

Reference:

Desai AS, et al. Outpatient Strategies for Heart Failure Management. Presented at: American Heart Association Scientific Sessions; Nov. 16-18, 2019; Philadelphia.

Disclosures: The project was funded by an unrestricted grant from Novartis. Desai reports he received honoraria from Alnylam, AstraZeneca, Abbott, Biofourmis, Boehringer Ingelheim, Boston Scientific, DalCor, Novartis, Relypsa and Regeneron and other research support from Alnylam, AstraZeneca, Novartis. Please see the abstract for all other authors’ relevant financial disclosures.

    Perspective
    Mark Drazner

    Mark Drazner

    This is a hot topic, which is implementation science. We have all of these therapies that we know can improve outcomes. We have large observational data showing that, as a general rule in our community, optimum therapy is not given to our patients at the rates that we would like. What are the strategies to try to improve that from a systematic basis?

    These investigators tried to have a navigator follow protocol and systematically adjust medical therapy. They were able to show that by doing that strategy, you could improve the utilization of guideline-directed therapy.

    One of the limitations of this is patients self-selected to participate in this, and then they used their control group as patients who decided not to participate in this. It is possible that patients who were willing to participate were somehow different. Maybe they were more proactive with their health, and the fact that they agreed to participate itself was the reason that they could have had their medications optimized even after they participated with the navigator.

    It’s a very interesting question, and it’s a creative strategy. We need creative strategies to improve optimization of guideline-directed medical therapy. We need more work. This needs to be tested on a more randomized basis to see if we get the outcomes that we all are hoping for.

    • Mark Drazner, MD
    • Clinical Chief of Cardiology
      Medical Director, LVAD and Cardiac Transplantation Program
      Professor
      University of Texas Southwestern Medical Center, Dallas

    Disclosures: Drazner reports no relevant financial disclosures.

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