Access to pharmacist-led rapid titration heart failure clinic for advanced heart failure patients is linked to better clinical outcomes
K L Chan, E Lee, C C Siu, W H Ho, A Lee, K Fan, S L Wong, K Y Cheng, K F Wong, K L WongAbstract
Background
Heart failure with reduced ejection fraction (HFrEF) is a significant public health challenge characterized by poor prognosis and frequent hospitalisations. The foundational quadruple therapy for HFrEF has been shown to improve survival, quality of life, and reduce HF-related hospitalisations when titrated to target doses. The STRONG-HF study demonstrated that accelerated dose titration with intense follow-up improved clinical outcomes. However, up-titration to target doses remains suboptimal due to barriers like drug non-adherence, knowledge gaps in optimisation strategies, and physician inertia. In October 2023, a Pharmacist-led Heart Failure Clinic (PHFC), in close collaboration with HF physicians and nurse specialists, was established at Grantham Hospital, a tertiary referral center for advanced HF in Hong Kong.
Purpose
This retrospective single-group pre-post study evaluated the effectiveness of pharmacist intervention on outcomes of our cohort of HF patients. The study assessed changes in 1) proportion of patients achieving ≥50% target dose of Guideline-Directed Medical Therapy (GDMT), 2) percentage of patients with dose titration to target dose, 3) number of HF-related hospitalisations and 4) plasma NT-proBNP levels.
Methods
Patients were enrolled in the PHFC by referrals from physicians between October 2023 and November 2025. The clinic followed a management protocol jointly developed by advanced HF physicians and pharmacists. GDMT doses were compared at baseline and up to 1 year post-enrolment, classified into <50% and ≥50% of target dose. The number of HF-related hospitalisations was compared 1 year before and after enrollment. NT-proBNP levels were compared at enrolment and up to 1 year post-enrollment, if available.
Results
A total of 207 patients were enrolled in the PHFC. Most patients were on SGLT2i as tolerated with counselling provided. For the rest of the 3 GDMT drugs: the proportion of patients achieving ≥50% of target doses significantly increased from 47.3% to 78.3% for Sacubitril/Valsartan, 29.2% to 47.4% for Beta-blockers and 68.0% to 80.6% for Mineralocorticoid Receptor Antagonists (MRA) (Figure 1). Additionally, the clinic successfully titrated a number of patients to target doses (Table 1a). Among the 114 patients (55%) followed up for more than 1 year, HF-related hospitalisations decreased significantly by 78.8% (p <0.001; Table 1b). Forty patients (19%) had NT-proBNP levels measured near the time of enrolment and up to 1 year post enrolment, revealing a significant reduction by 32.0% (p <0.05; Table 1b).
Conclusion
The PHFC for HF patients led by pharmacists represents a promising and feasible approach. This study shows that accelerated medication titration can be safe and effective for HF patients, even those considered "drug refractory". Incorporating pharmacists into the multidisciplinary care team enhances patient outcomes through proactive medication management and monitoring.Figure 1, Table 1a, Table 1bFor image description, please refer to the figure legend and surrounding text.