Key result
Pharmacist-led remote GDMT optimisation linked to ~127-day faster quadruple therapy vs historical care.
Why the study?
Real-world GDMT uptitration in HFrEF remains slow and incomplete due to outpatient constraints and infrequent follow-up, and evidence for centralised pharmacist-led remote models across multi-hospital regional networks is limited.
Does a centralised pharmacist-led remote GDMT optimisation service shorten time to maximum tolerated quadruple therapy in patients with HFrEF compared with historical standard care?
Observational (n=366)
Yes
Does a centralised pharmacist-led remote GDMT optimisation service shorten time to maximum tolerated quadruple therapy in patients with HFrEF compared with historical standard care?
A centralised pharmacist-led remote GDMT optimisation service reduced time to quadruple therapy achievement by over four months and lowered 90-day heart failure hospitalisations compared with historical standard care.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The guys see around 50 to 60 patients a week and they make several touchpoints with individuals, where therapy is up-titrated. And we've shown over a nine-month period that individuals can be titrated up to the four pillars. And then at the point of discharge, around 92% of our patients are on the four pillars. And this is undertaken between six to eight weeks, and patients are able to then be transferred back to primary care for ongoing maintenance review and monitoring. This has significantly reduced outpatient appointment activity, significantly reduced in-patient rehospitalisations and has had a big impact on an improvement in LV function, meaning that many of these patients now don't need to receive device therapy.”
Remote pharmacist-led GDMT titration was associated with faster quadruple therapy in HFrEF; hypothesis-generating and requires RCTs before practice change.
Background Guideline-directed medical therapy (GDMT) reduces mortality and hospitalisation in heart failure with reduced ejection fraction (HFrEF), yet real-world uptitration remains slow and incomplete due to outpatient constraints and infrequent follow-up. Centralised pharmacist-led remote models offer scalable solutions, but evidence from multi-hospital regional networks is limited. Purpose To evaluate whether a centralised pharmacist-led remote GDMT optimisation service across five hospitals shortened time to quadruple therapy achievement and increased optimisation rates in HFrEF compared with historical standard care. Methods We conducted a pre-specified multi-centre observational study comparing a centralised pharmacist-led remote service (September 2024–September 2025; n=192) with a historical control cohort from the same five hospitals (January 2023–August 2024; n=174). Eligible patients with HFrEF post-discharge or following outpatient review submitted daily remote monitoring data (blood pressure, heart rate, symptoms); pharmacists performed protocoled asynchronous uptitration twice weekly. The primary endpoint was time to maximum tolerated GDMT, defined as achievement of target or maximum tolerated doses of all four pillars (ACEi/ARNi, beta-blocker, MRA, SGLT2i). Heart failure hospitalisation at 90 days was a pre-specified secondary endpoint. Results Baseline characteristics were well matched: mean age 59.4 vs 61.4 years, male sex 75.5% vs 69.7%, mean LVEF 29.8% vs 28.7%. Median time to GDMT optimisation was 52 days (IQR 30.5–68) in the remote service versus 179 days (IQR 98.5–311) in controls (p<0.001), an absolute reduction of 127 days (>4 months). The proportion achieving optimal quadruple GDMT by 90 days was significantly higher in the remote cohort compared with historical care (93.2% vs 23.0%; p<0.001). Heart failure hospitalisation occurred in 0/192 (0%) versus 5/174 (2.9%) patients at 90 days (p=0.024). No serious adverse events attributable to remote titration were recorded. Conclusion A centralised pharmacist-led remote GDMT optimisation service across five hospitals reduced time to quadruple therapy achievement by over four months and significantly increased the proportion of patients reaching optimal medical therapy, compared with historical standard care. This was associated with fewer heart failure hospitalisations and no attributable serious adverse events. The asynchronous hub-based model is scalable across regional networks and offers a pragmatic strategy to close the persistent gap between guideline evidence and clinical practice. Prospective randomised evaluation is warranted.
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Kirupananthavel et al. (2026) conducted an observational in Heart failure with reduced ejection fraction (HFrEF) (n=366). Centralised pharmacist-led remote GDMT optimisation service vs. Historical standard care was evaluated on Time to maximum tolerated GDMT, defined as achievement of target or maximum tolerated doses of all four pillars (ACEi/ARNi, beta-blocker, MRA, SGLT2i) (Absolute reduction 127 days, p=<0.001). Centralised pharmacist-led remote GDMT optimisation reduced median time to maximum tolerated quadruple therapy vs historical care (52 vs 179 days; p<0.001).
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