Authors (including presenting author) :
Ip NS(1), Ho KH(2), Mow HC(2), Chu HY(2), Shek PS(2), Choi CW(2), Chung SW(2), Cheung C(2), Yam PW(2), Chu LM(1)
Affiliation :
(1)Department of Pharmacy, (2)Department of Medicine and Geriatrics, Tuen Mun Hospital
Introduction :
The aging trend is a major concern in Hong Kong. The incidence of heart failure doubles with each decade of life. Due to high mortality and hospitalization rate, heart failure with reduced ejection fraction (HFrEF) causes growing health burden in Hong Kong. Despite therapeutic advances, local study showed that the uptake of guideline directed medical therapy (GDMT) in clinical practice was suboptimal, mainly due to the challenge of the need for frequent physician follow up for drug titration. A multidisciplinary HF clinic was implemented, aiming early achievement of target doses of GDMT as outlined by the latest international guideline.
Objectives :
To provide ambulatory care service in optimizing GDMT and improve clinical outcomes for HFrEF patients
Methodology :
HFrEF patients referred were co-managed by cardiologist, pharmacist and cardiac nurse. Patients were stratified by cardiologist in the first visit. Patients with unstable clinical conditions or end-stage diseases were followed by cardiologist subsequently for advanced therapies/ palliative care while other recruited patients were followed by pharmacist and cardiac nurse for drug titration and self-care assessment respectively until GDMT optimized. A repeated echocardiogram was reviewed by cardiologist before case closed to routine care.
Result & Outcome :
From 10/2020-12/2024, 319 patients (83.2% male) with a median age of 59 were discharged from clinic after GDMT optimization (median follow-up of 7.9 months). The mean modified optimal medical therapy score, an aggregate score of HFrEF quadruple therapy categorized from suboptimal (score 0–4) to optimal (score 8), improved from 4.7 to 7.2 from initial visit to clinic discharge (p<0.001). There was an increase in patients attaining target doses of GDMT upon clinic discharge (ACEI/ ARB/ ARNI: from 13.0% to 77.7%, p<0.001 and evidence-based beta-blockers: from 5.1% to 36.0%, p<0.001). Patients were associated with reduced 12-month HF-related readmission rate, when compared to prior recruitment (6.7% vs 23.4%, p<0.001). 1-year mortality rate was 3.3% in our patient group, which was lower than 8.8% from data of European Society of Cardiology registry. Left ventricular ejection fraction was improved from a mean of 25.8% to 44.1% (p<0.001) at clinic discharge. There was significant improvement of 6-minute walk test from 352m to 438m (p<0.001).
The co-care model of HF clinic improved use of GDMT and was associated with lower rates of mortality and HF hospitalization. Stratifying clinically stable patients under management of pharmacist and cardiac nurse supports early optimization of GDMT, monitoring of adverse drug reactions and patient self-care empowerment. Cardiologist can devote more time to the care of patients in unstable conditions, making better use of resources to cope with the growing patient demands.
