Abstract 905: Nurse-led Titration of Beta-blockers Can Improve Outcomes in Chronic Heart Failure Patients in the Community
Background: Chronic heart failure (CHF) is associated with high mortality and morbidity rates. Large scale randomised controlled trials have proven the benefits of angiotensin converting enzyme inhibitors (ACEI) and beta-blockade in reducing such events and evidence-based guidelines mandate their use. In spite of these recommendations, these important therapies are under-prescribed and under-utilised.
Method: The aim of the study was to determine the effect of nurse-led medication titration in the context of heart failure management programs based in the community. Heart failure program co-ordinators throughout Australia were asked to recruit 10 –20 patients each. Programs that allowed heart failure nurses to titrate ACEIs, angiotensin receptor blockers (ARBs) and/or beta-blockers (15 programs) were compared with those programs that did not allow the titration of these medications (29 programs). All patients were followed up for six months to determine prescribing patterns, hospitalisation and mortality rates.
Results: Demographic characteristics were similar between the nurse-led medication titration (NLT) programs (n=229, 71% male aged 65+14 years) and usual care (UC) programs (n=255, 69% male aged 70+12 years). The percentage of patients in each NYHA functional class was similar between groups and mean ejection fraction was approximately 27+9.5% for both groups. Patients participating in the NLT programs for at least six months, were significantly more likely to be prescribed beta-blockers (RR 1.13, 95%CI 1.04 –1.23, p=0.006) and at optimal dose (RR 1.50, 95%CI 1.17–1.93, p=0.001). In patients that were prescribed low dose beta-blockers at baseline, 25 (31%) patients in NLT programs had an increase in dosage after six months compared with 26 (25%) patients in UC programs (p=0.05). All-cause hospital admissions and mortality were significantly reduced in patients participating in NLT programs (HR 0.53, 95%CI 0.34 – 0.82, p=0.005).
Conclusion: This study has shown the benefits of nurse-led titration of beta-blockers in the community. Clinical outcomes for this cohort of patients could be further improved by adherence to evidence-based practice, and optimisation of these medications by heart failure nurses in a CHF program.