Remote rapid titration of heart failure therapies

Background/Introduction Heart failure remains a global health challenge contributing significantly to morbidity, mortality, and health care burden. In the UK alone, approximately 920,000 people have a diagnosis of heart failure, and the numbers are predicted to double by 2040. There is strong evidence demonstrating the benefit of timely titration of lifesaving drug treatment in this group of patients. Using telemonitoring, this can be achieved safely and effectively within 6- 10 weeks of diagnosis to improve patient outcomes, reduce hospital admissions with acute heart failure, and to ensure decisions regarding lifesaving therapies, including device implantation, are made within the recommended time frame. Purpose To introduce and evaluate the effectiveness of a novel rapid titration service to optimise and revolutionise the management of heart failure patients. Methods Patients with impaired LV systolic function (LVEF ≤40%) were prospectively enrolled to the dedicated titration service for guideline-directed medical therapies. Referrals were received from 5 hospital sites, within 2 NHS trusts, ensuring a diverse patient population. Patients were required to input their blood pressure and heart rates daily, and complete symptom assessment questionnaires on a secure digital platform. They were reviewed twice weekly remotely for adjustments of their heart failure therapies. Blood sampling for renal function, electrolytes, and NT-proBNP were performed at baseline and monitored at 3 weekly intervals, or closer monitoring if clinically indicated, until the patients were fully optimised. Transthoracic echocardiograms were performed 3 months post-optimisation. Results A total of 105 patients were enrolled over a 6 month period (73% male). Patients were referred from both inpatient and outpatient services across multiple cardiology subspecialities including heart failure, inherited cardiomyopathy, cardio-oncology, and general cardiology. The mean reduction in NT-proBNP from admission to optimisation was 1315ng/L. Additionally, following optimisation there was a mean increase in LV systolic function LVEF of 14.9%. There were no presentations to hospital or inpatient admissions secondary to decompensated heart failure. Two patients developed treatment-related hyperkalemia, treated with potassium binders without the need for treatment discontinuation. Conclusions Patients recruited to a dedicated rapid titration service delivering personalised care, demonstrated a reduction in NT-proBNP levels and improvement of LV systolic function. Importantly, patient safety was maintained, with side-effects and adverse effects, such as hyperkalaemia, identified early without the need to compromise treatment. These findings support the use of remote rapid titration in patients with heart failure to optimise patient outcomes.