Outcome of Titrating Guideline Directed Medical Therapy in Heart Failure Patients at 90-Day Post-Hospital Discharge

Purpose Optimal doses of guideline-directed medical therapy (GDMT) are a key component for reducing hospital readmissions in patients with heart failure with reduced ejection fraction (HFrEF). Pharmacist-led medication titration may allow for more rapid up-titration of GDMT in the clinic setting. The objective of this study was to determine the proportion of heart failure patients discharging from the hospital on non-target doses of GDMT. This population represents the group of patients who could benefit from pharmacist-led medication titration. Methods This Institutional Review Board approved, single-center, retrospective, observational chart review study included patients who were at least 18 years old and were discharged with the diagnosis of HFrEF (EF ≤40%) between July 1, 2016 to December 31, 2016. The optimized group consisted of patients at ≥50% or maximum tolerated doses of GDMT (ACEI/ARB/ARNI and BB) at hospital discharge. The potential to optimize group consisted of patients on Results 103 patients were included in the study. At discharge, 37% of patients were on optimal doses of GDMT, whereas in 63% of patients one or both therapies were not optimized at discharge. Rate of hospital readmission at 90 days was numerically lower in patients in the optimized group compared to potential to optimize group at discharge (39% vs. 46%, P= 0.56). Reflecting national data, the number of patients who were discharged on ≥50% of GDMT was small (n= 5). This group of patients had zero readmissions during 90 days. Out of the 65 patients in the potential to optimize group at discharge, only 34% were optimized on GDMT doses by standard of care during the 90-day follow-up period. Patients who were titrated up to ≥50% of GDMT (n=2) during 90 days had zero readmissions. The most common limiting factors for dose titration in the maximum tolerated dose group were hypotension, elevated serum creatinine, and bradycardia. Conclusions In a large academic medical center, the majority of patients leaving the hospital were not optimized on GDMT doses at discharge or during the 90-day follow-up period under routine care. While the 90-day readmission rate between the groups were similar, the sub-analysis showed patients on ≥50% of GDMT (n=7) had no readmissions during the 90 days. A significant opportunity therefore exists to leverage pharmacy expertise to optimize GDMT in this population.