Corey Diamond, PharmD
Chiefly managed by pharmacotherapy, heart failure with reduced ejection fraction (HFrEF) includes pharmacists on the health care team playing an increasingly pivotal role in optimizing therapy for patients. Findings from a study published in the Journal of the American College of Clinical Pharmacology on January 24, 2024, found that pharmacist-led guideline-directed medical therapy for patients with HFrEF resulted in a higher degree of optimal HF therapy and improved echocardiographic parameters compared to baseline.
Medication optimization
Ladhar and colleagues conducted a pharmacist-led medication optimization study at an outpatient telehealth clinic at St. Paul’s Hospital within the Providence Healthcare health system in Canada. Eligible patients were referred by cardiologists and underwent virtual/telephone encounters with a pharmacist to optimize guideline-direct medical therapy.
The clinic’s guideline-directed medical therapy targeted optimization of four medications: angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers; beta-blockers; mineralocorticoid receptor antagonists; and sodium-glucose cotransporter-2 inhibitors.
These medications were then systematically optimized per the Canadian Cardiovascular Society HF guidelines. In addition to managing a patient’s medications, pharmacists screened for comorbidities and collaborated with physicians on prescriptions. Referral criteria for the PHARM-HF clinic included HFrEF diagnosis, left ventricular ejection fraction (LVEF) of less than or equal to 40%, stability, need for guideline-directed medical therapy optimization, regular bloodwork capability, virtual care suitability, and exclusion from multidisciplinary HF clinic care.
The typical patient progression included two to six encounters over 6 months, with appointments every 1 to 3 weeks. The clinic operated 1 day per week, with patients discharged to referring physicians upon achieving maximum-tolerated therapy.
Outcomes and results
The study, called PHARM-HF, was a retrospective, pre–post study that evaluated chart reviews of 81 patients from January 2021 to August 2022. The primary outcome was the modified optimal medical therapy (OMT) score, a validated scoring system that quantifies the optimization of a patient’s HF medication. An OMT score of suboptimal, acceptable, and optimal fell in the ranges of 0 to 4, 5 to 7, and 8, respectively.
The researcher’s secondary outcomes were the proportion of patients on all four targeted medications at any dose and the proportion of patients on all four medications at 100% target dose.
The study findings demonstrated a statistically significant increase in the median modified OMT score of 6 at baseline compared to 8 at discharge. The proportion of patients considered to be on optimal therapy increased from 7% to 73% compared to baseline. Moreover, there was a notable improvement in treatment adherence, with the percentage of patients adhering to all four medication classes rising from 35% to 77%. Additionally, the proportion of patients reaching the target doses for guideline-directed medical therapy increased from 2% to 16%.
In terms of clinical outcomes, researchers found a cumulative incidence of HF hospitalization or death of 5%. About 40% of patients in the study had an echocardiogram available at a 1-year follow-up that demonstrated a statistically significant improvement in median LVEF compared to baseline, from 30% to 38%. The authors did not see a statistically significant improvement in quality-of-life KCCQ-12 scores, although only 20% completed the questionnaire at baseline.
Pharmacist’s role
In the intricate landscape of CV health, the management of HFrEF is challenging for health care professionals. Guideline-directed medical therapy represents a comprehensive approach to treating HF, integrating evidence-based recommendations into a framework that aims to improve patient outcomes and enhance the quality of care—though adherence may not always be followed. As such, clinical pharmacists are beginning to play a crucial role in the optimization of guideline-directed medical therapy across the health care landscape.
The study highlighted that although many sites in Canada and the United States have successfully incorporated pharmacist-led HFrEF medication optimization services, this remains far from the standard of care, and resources are lacking in many HF clinics.
“As the global prevalence of HF continues to rise, the need for specialized clinicians in HF management is also increasing. Pharmacists’ unique skills and knowledge of medications ideally position them to be involved in medication optimization,” said the authors. ■