Intensive pharmacist-led guideline-directed medical therapy for hospitalized heart failure patients: a single-center retrospective cohort study

Background Guideline-directed medical therapy (GDMT) improves outcomes in heart failure with reduced ejection fraction (HFrEF). However, implementation remains suboptimal, and evidence for inpatient pharmacist-led interventions is limited. We evaluated the association between a pharmacist-led electronic medical record (EMR)-embedded checklist and GDMT use in hospitalized patients with acute heart failure. Methods A single-center, retrospective, non-randomized study with a historical control group was conducted. Adult patients hospitalized with acute heart failure from October 2021 to March 2023 were enrolled. Patients admitted between October 2022 and March 2023 formed the pharmacist-led GDMT checklist intervention group, whereas those admitted between October 2021 and March 2022 served as historical controls. Primary outcomes were discharge implementation and new initiation rates of individual GDMT agents (renin–angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists [MRA], sodium–glucose cotransporter-2 inhibitors [SGLT2i]) and quadruple therapy. Exploratory multivariable logistic regression was performed for quadruple therapy use at discharge in patients with HFrEF. Secondary outcomes included target-dose achievement, exploratory 90-day heart failure readmission, and all-cause mortality. Results A total of 103 patients were included (49 controls, 54 intervention). Among patients with HFrEF (22 controls, 23 intervention), the intervention group had higher prescription rates of MRA (87.0% vs. 59.1%, p = 0.047) and SGLT2i (95.7% vs. 72.7%, p = 0.047). Quadruple therapy was achieved in 78.3% vs. 40.9% ( p = 0.016). The proportion of patients who newly achieved quadruple therapy during hospitalization was also higher in the intervention group (83.3% vs. 35.0%, p = 0.038). In the exploratory multivariable model, the intervention remained associated with higher odds of quadruple therapy use at discharge. Target-dose achievement was similar between groups. In mildly reduced/preserved EF, discharge SGLT2i use tended to be higher in the intervention group ( p = 0.062). Exploratory 90-day outcomes showed no clear between-group differences and were limited by incomplete follow-up and insufficient statistical power. Conclusions The pharmacist-led EMR-embedded checklist intervention was associated with higher discharge implementation and in-hospital initiation of HFrEF-directed GDMT, particularly MRA, SGLT2i, and quadruple therapy. This simple checklist-based approach may support evidence-based pharmacotherapy optimization and warrants confirmation in larger multicenter studies with long-term follow-up.