American Heart Association
American Heart Association
Perspective from Mark Drazner, MD
December 02, 2019
2 min read

Remote titration of HF medications may increase utilization

Perspective from Mark Drazner, MD
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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


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.