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Virtual heart failure consultations increase guideline-directed medical therapy

24 Jan 2023
Heart failure

Guideline-directed medical therapy (GDMT) for heart failure management has been shown to improve clinical outcomes and quality of life (QoL).1 However, would employing peer-to-peer intervention increase GDMT optimization for patients with heart failure, especially in-hospital, thereby improving further post-discharge outcomes and medication use?

A pilot study at a large tertiary-care hospital identified patients with heart failure with reduced ejection fraction (HFrEF) admitted to non-cardiology medicine services (for all causes). Major exclusion criteria included end-stage renal disease (ESRD), hemodynamic instability, concurrent COVID-19 infection, and hospice care. Of the 242 patients identified, 91 were eligible, with 52 patients randomized to ‘clinician-level’ virtual peer-to-peer consult intervention, while 39 were randomized to usual care.

The consult intervention comprised GDMT recommendations (provided to the clinician by an advanced practice provider utilizing virtual consults and follow-up phone calls). Additionally, patients were provided information on medication costs, with follow-up appointments already scheduled post-discharge. Usual care was not defined in the paper.

The first primary endpoint was the proportion of patients with new GDMT initiation or use. The other co-primary endpoint evaluated changes to heart failure optimal medical therapy (OMT) scores (including target dosing for evidence-based β-blockers, ACEI/ARB/ARNI, MRA, and SGLT2i).

Heart failure in-hospital interventions may increase new GDMT and dose optimization

Baseline characteristics were comparable between the groups, including similar GDMT use on admission. However, more patients initiated or continued GDMT with intervention than with usual care (e.g., ACEi/ARB/ARNI [71% vs. 49%; p = 0.04]). After factoring in admission scores, changes in OMT scores at discharge were higher in the intervention group (+0.44) versus the usual care group (-0.31). The absolute difference between the score was +0.75 (p = 0.04). Virtual consult interventions significantly increased the composite OMT score by discharge through new GDMT initiations/continuations in-hospital, with fewer discontinuations post-discharge.


Less than half of the patients identified were eligible for the consult interventions (due to ESRD or Covid-19 infections). However, this study showed peer-to-peer consult interventions may offer a strategy to address clinical inertia in GDMT use in patients with heart failure. Therefore, ‘clinician-level’ interventions may improve long-term clinical outcomes, especially regarding in-hospital GDMT initiation and dose optimization.

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Author: Saskia van Tetering

References:

  1. Heidenreich PA, Bozkurt B, Aguilar D, Lallen LA, Byunt JJ, Colvin MM, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/ American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145:e895–e1032.
  2. Rao VN, Shah A, McDermott J, Barnes SG, Murray EM, Kelsey MD, et al. In-Hospital Virtual Peer-to-Peer Consultation to Increase Guideline-Directed Medical Therapy for Heart Failure: A Pilot Randomized Trial. Circ Heart Failure. 2022.

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