Dr. Pahwa
Clinical question: Can a virtual care team increase the number of patients with chronic heart failure (CHF) on goal-directed therapy during hospitalization?
Background: Maximizing goal-directed medical therapy (GDMT) in patients with CHF with reduced ejection fraction improves mortality. However, on discharge, 40% of patients are on a beta blocker, angiotensin-converting enzyme inhibitors (ACE inhibitors), or angiotensin II receptor blockers (ARBs), and mineralocorticoid receptor antagonists. The study team piloted a virtual care team to optimize the intensity of medications for patients with CHF who were hospitalized for other reasons.
Study design: Randomized control prospective trial (by birth month)
Setting: Three hospitals in a Boston health care system
Synopsis: The study team enrolled patients with a history of CHF with reduced ejection fraction (<40%) who were hospitalized for any reason from October 2021 to June 2022 in a non-ICU setting. They excluded patients who spent time in ICU, required circulatory support, were diagnosed with acute coronary syndrome or stroke, had recent surgery, or were hypotensive. A virtual care team of physicians and pharmacists reviewed patients’ charts in the study group to maximize quadruple therapy. They made recommendations in a progress note and paged the treating team. The primary outcome was change in a GDMT score. Secondary was new initiations or up-titrations. Safety outcomes were hypotension, bradycardia, acute kidney injury, or hypokalemia. There were 107 encounters (83 patients) in the intervention group and 145 encounters (115 patients) in the usual-care group. The mean age was 69 years with 66% of the patients being men and 73% white. The median hospital stay was six days in both groups. About 25% in each group were hospitalized for heart failure exacerbations. The mean GDMT score was 1.1 in the intervention group compared to 0.4 in usual care (P <0.001). The intervention group had twice as many initiations (P=0.001) or up-titrations (P=0.002) as the usual care. There were no significant differences (P= 0.30) in safety events (28% versus 21%), the most common being hypotension.
Bottom line: A virtual care team can safely provide input on the optimization of a patient’s medications for chronic heart failure.
Citation: Bhatt AS, Varshney AS, et al. Virtual care team guided management of patients with heart failure during hospitalization. J Am Coll Cardiol. 2023;81(17):1680-93.
Dr. Pahwa is director of the internal medicine sub-internship, at Johns Hopkins Hospital and associate professor of pediatrics at Johns Hopkins University School of Medicine in Baltimore.