Authors (including presenting author) :
Mak WL(1), Wong WY(2), Chau M (2), Wong KH (1), Cheng YH(1), Wong SY(1), Chan YH(1), Lam CS(1), Wong CW(1)
Affiliation :
(1) Department of Medicine and Geriatrics, Pok Oi Hospital, Au Tau, Yuen Long, Hong Kong , (2) Department of Pharmacy, Pok Oi Hospital, Au Tau, Yuen Long, Hong Kong
Introduction :
Heart failure (HF) is a public health concern and a leading cause of morbidity and mortality.
Because of aging of population and life‐prolonging cardiovascular treatments and care,
prevalence of HF and HF‐related hospital admissions and, consequently, overall costs are
increasing. The European Society of Cardiology has recently updated its guideline in 2021, in which it gives 4 classes of drugs a class 1A recommendation for heart failure with reduced ejection fraction (HFrEF) patients. This includes Angiotensin-converting enzyme inhibitors (ACEI) / Angiotensin receptor-neprilysin inhibitor (ARNI), beta-blockers, mineralocorticoid receptor antagonist (MRA) and sodium-glucose co-transporter 2 inhibitors (SGLT-2 inhibitor). In particular, the first 3 classes require dose up titration to achieve maximum tolerated target doses. To reduce heart failure hospitalisation and mortality, numerous countries have adopted a multi-disciplinary team approach in HF management. Due to their expertise in drug therapy, pharmacists are particularly well-suited to provide patients the necessary medication interventions to optimize medication regimen and improve medication adherence. However, the role of pharmacist in heart failure has not been evaluted in local community setting.
Objectives :
The Pharmacist led Heart Failure Clinic (PHFC) is a protocol driven ambulatory care service with the aims to provide education and counselling to enhance patient's adherence, empowerment and satisfaction. It also serves to optimise titration of guideline directed medications for HF patients. This study aims to assess the efficacy of a pharmacist-led heart failure clinic program on patient's re-admission rates and mortality. In addition, echocardiographic outcomes were evaluated where baseline and follow up echocardiogram were available.
Methodology :
Patients between the age of 18 and 80 years old who were admitted via the Accident and Emergency Department with diagnosis of heart failure with reduced ejection fraction (HFrEF) for the period between October 2020 and September 2021 were studied. The study group consisted of patients recruited to PHFC by cardiology team referral/consultation. The control group consisted of patients with HFrEF not recruited in PHFC within the same period. Cases will be excluded if they have any of the following: 1) end stage HF defined by New York Heart Association (NYHA) class 4; 2) presence of other major organ comorbidities e.g., chronic kidney disease defined by glomerular filtration rate (GFR) less than 30 ml/min/1.73m2 , presence of liver cirrhosis, dementia 3) concomitant malignancy 4) patients with limited mobility e.g., chair bound or bedbound. After enrolment into PHFC, patients would receive telephone counselling prior their first consultation to understand the benefits of HF drugs titration and to receive advice on lifestyle modifications if applicable. A short video clip to reinforce the given information was also available for them to view at home. During the face to face consultations, pharmacist would monitor patient's drug adherence, HF symptoms, signs, lifestyle and titrate the HF medications as per predefined protocol. Patients were followed for total 6 months in the study with PHFC arranged in between physicians’ appointments. Cardiologists’ attention could be sought if case of suspected red flag signs during PHFC. Three classes of medication were evaluated in this study, i.e., angiotensin blockers (ACEI/ARB/ARNI), betablocker & MRA (SGLT 2 inhibitor was not listed in HADF for HF at time of study). Patients would be discharged from PHFC if HF medications had been maximized to their highest tolerated dose. Data were retrieved using the Clinical Data and Analysis and Reporting System (CDARS) of the Hospital Authority as well as Electronic Patient Record (ePR).
Result & Outcome :
We retrospectively studied a total of 129 patients who were admitted with a diagnosis of congestive heart failure in a regional hospital between October 2020 and September 2021. Patients were divided into two groups; 33 patients were recruited into the pharmacist led heart failure clinic program (PHFC participants) following discharge and 96 patients were managed with usual standard of care (control). We conducted detailed reviews to compare the use of evidence-based heart fail. Lower rate of unplanned HF re-admissions was observed in PHFC participants as compared with control after the launch of pharmacist-led heart failure clinic program at 1 month (6.1% vs 22.9%, P = 0.032), 3 months (12.1% vs 40.6%, P = 0.003) and 6 months (18.2% vs 45.8%, P=0.005). After adjustment of baseline characteristics by Cox-regression, the result remains significant for 3-month re-admission (HR 0.203, 95%CI 0.067-0.615, P=0.005) and 6-month re-admission (HR 0.278, 95% CI 0.109-0.707, P=0.007). There was a trend in reduction in 1month unplanned HF re-admissions after adjustment of baseline characteristics (HR 0.26, 95%CI 0.05-1.22 P=0.088). There was no significant difference in 6-month HF-related mortality (6.1% vs 7.3%, P =1.0) and all-cause mortality (6.1% vs 9.4%, P=0.728). There were significantly more patients achieving maximum tolerated dose in PHFC participants as compared with control group in angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) or Angiotensin receptor-neprilysin inhibitor (ARNI) (93.9% vs 33.7%, P< 0.005), beta-blocker (84.8% vs 30.2%, P=0.007) and mineralocorticoid receptor antagonist (MRA) (90.9% vs 49%, P< 0.005). There was a significant increase in LV ejection fraction (LVEF) in PHFC participants (+13.55%, IQR +4.5-19.0%) as compared to control group (+1.5%, IQR -4.5–12.8%), P=0.006. LV end systolic diameter (LVESD) was markedly decreased in the PHFC participants (-0.48cm, IQR -1.20– -0.13) as compared with control group (+0.00cm, IQR -0.4– 0.36), P=0.008. Subgroup analysis based on gender confirmed the significant LVESD reduction existed in both male and female. LA volume index (LAVI) was also significantly reduced in PHFC group (-16.81 ml/m2, IQR -24.50– -7.45) as compared with control group (4.40ml/m2, IQR -7.5–14.2), P=0.037.
Conclusion: Pharmacist-led heart failure clinic was associated with an increase in use of guideline directed medical therapy as well as reduction in heart failure re-admission. Echocardiographic data suggests that early up titration of HF medication promotes cardiac reverse remodelling.
