Protocolised up-titration of guideline-directed medical therapy in a nurse-led clinic increased mean LVEF from 27.6% to 38.8%, and each 5% increase in LVEF was associated with reduced mortality (HR 0.84).
Cohort (n=378)
No
Does protocolised up-titration of guideline-directed medical therapy in a nurse-led clinic improve left ventricular ejection fraction and clinical outcomes in patients with new-onset HFrEF?
Protocolised up-titration of guideline-directed medical therapy in a specialised nurse-led clinic achieves high target doses and significant improvements in LVEF, which correlates with reduced mortality in new-onset HFrEF.
Effect estimate: HR 0.84 (95% CI 0.75-0.94)
p-value: p=0.002
OBJECTIVE: Recent studies have reported suboptimal up-titration of heart failure (HF) therapies in patients with heart failure and a reduced ejection fraction (HFrEF). Here, we report on the achieved doses after nurse-led up-titration, reasons for not achieving the target dose, subsequent changes in left ventricular ejection fraction (LVEF), and mortality. METHODS: From 2012 to 2018, 378 HFrEF patients with a recent (< 3 months) diagnosis of HF were referred to a specialised HF-nurse led clinic for protocolised up-titration of guideline-directed medical therapy (GDMT). The achieved doses of GDMT at 9 months were recorded, as well as reasons for not achieving the optimal dose in all patients. Echocardiography was performed at baseline and after up-titration in 278 patients. RESULTS: Of 345 HFrEF patients with a follow-up visit after 9 months, 69% reached ≥ 50% of the recommended dose of renin-angiotensin-system (RAS) inhibitors, 73% reached ≥ 50% of the recommended dose of beta-blockers and 77% reached ≥ 50% of the recommended dose of mineralocorticoid receptor antagonists. The main reasons for not reaching the target dose were hypotension (RAS inhibitors and beta-blockers), bradycardia (beta-blockers) and renal dysfunction (RAS inhibitors). During a median follow-up of 9 months, mean LVEF increased from 27.6% at baseline to 38.8% at follow-up. Each 5% increase in LVEF was associated with an adjusted hazard ratio of 0.84 (0.75-0.94, p = 0.002) for mortality and 0.85 (0.78-0.94, p = 0.001) for the combined endpoint of mortality and/or HF hospitalisation after a mean follow-up of 3.3 years. CONCLUSIONS: This study shows that protocolised up-titration in a nurse-led HF clinic leads to high doses of GDMT and improvement of LVEF in patients with new-onset HFrEF.
Nauta et al. (Mon,) conducted a cohort in New-onset heart failure with reduced ejection fraction (HFrEF) (n=378). Protocolised up-titration of guideline-directed medical therapy vs. Baseline was evaluated on All-cause mortality per 5% increase in LVEF (HR 0.84, 95% CI 0.75-0.94, p=0.002). Protocolised up-titration of guideline-directed medical therapy in a nurse-led clinic increased mean LVEF from 27.6% to 38.8%, and each 5% increase in LVEF was associated with reduced mortality (HR 0.84).