Specialist pharmacist-led rapid optimisation of patients with heart failure with reduced ejection fraction in the outpatient setting
G Campbell, J Webb, T F Ismail, G Carr-WhiteAbstract
Background
The publication of STRONG-HF has demonstrated the safety and efficacy of rapid-optimisation of guideline directed medical therapy post hospitalisation [1]. Heart failure (HF) pharmacists play a critical role within the multidisciplinary team in the prescribing and titration of medications in heart failure with reduced ejection fraction (HFrEF)[2]. Locally, our pharmacist-led clinics have demonstrated efficient optimisation over 3 months, alongside providing holistic medication review [2].
Purpose
To evaluate pharmacist-led rapid optimisation for patients with HFrEF in the outpatient setting.
Methods
Retrospective analysis was undertaken on patients who had undergone rapid optimisation in existing HF pharmacist clinics between Dec 2023-June 2025. Patients were referred either post discharge or directly from a HF consultant clinic. Patients were seen in-person on four occasions at 2-week intervals (or as close as possible allowing for staff and patient availability). At each appointment clinical examination, medication review, and a renal profile was completed. Patients were only included for analysis, who had undergone repeat imaging to re-assess left ventricular ejection fraction (LVEF). Statistical analysis was undertaken on pre-and post-LVEFs using a paired t-test.
Results
A total of 25 patients, (mean age 48, 19 male) were included for analysis. Twenty patients had been referred from outpatient clinics and 5 following an inpatient discharge. No patients were considered optimised at baseline. At discharge, 100% of patients were optimised. For angiotensin converting enzyme inhibitor/angiotensin receptor-neprilysin inhibitor, 16 (64%) were on the maximum licensed dose, with 9 (36%) on the maximum tolerated. For beta-blockers, 14 (56%) were on the maximum licensed dose, with 11 (44%) on the maximum tolerated. For mineralocorticoid receptor antagonists, 9 (36%) were on the maximum licensed dose and 16 (64%) on the maximum tolerated. All patients, 25 (100%) were on the maximum licensed dose of sodium-glucose cotransporter-2 inhibitors. The reasons preventing achievement of the maximum licensed dose were hypotension (n=25), bradycardia (n=7), patient preference (n=3), hyperkalaemia (n=1). The average time between each appointment was 2.5 weeks. There was no significant impact on blood pressure, heart rate, potassium or creatinine and no patients discontinued rapid optimisation. The average LVEF at baseline was 28.8% (SD±7.6%) and following optimisation was 39.9% (SD±9.2%) (p <0.01%). The average time to follow up imaging was 25 weeks (min 5, max 59).
Conclusion
HF pharmacist-led rapid optimisation in the outpatient setting resulted in significant improvement in LVEF, with all patients discharged on optimal HF therapy. Our data builds on from STRONG-HF, demonstrating success in a real-world setting with an adapted protocol. Full implementation of this service could lead to reduced hospitalisations and reduced mortality.