title: Success of a multidisciplinary heart failure clinic for initiation and up-titration of key therapeutic agents.
abstract: BACKGROUND
  Heart failure has a poor prognosis, yet drugs known to improve outcomes are either not prescribed, or prescribed at sub-therapeutic doses. The National Service Framework (NSF) for coronary heart disease recommended specialist heart failure clinics to address this problem but their efficacy has not been evaluated.
  
  
  OBJECTIVE
  To determine the effectiveness of a protocol-driven heart failure clinic staffed by nurse and pharmacist specialists for improving symptoms and optimising treatment with key therapeutic agents, without adversely affecting renal function.
  
  
  RESULTS
  Of the 234 patients with at least one follow-up visit, 127 (57%) were receiving none or only one key therapeutic agent when first seen, this was reduced to 25 patients (11%) at most recent follow-up. The improvement in prescription rates was accompanied by significant up-titration of dose, the proportion of patients on "medium" or "high" doses rising from 43 (18%) to 134 (57%) for beta-blockers, and from 129 (55%) to 201 (86%) for ACE-inhibitors/angiotensin receptor blockers. Clinical improvement was reflected in reductions in patients with NYHA functional classes III and IV (93 (40%) to 53 (23%)), and in patients with moderate or severe symptoms. Significant reductions in alcohol consumption and cigarette smoking were recorded. Up-titration of treatment was associated with reductions in heart rate and systolic blood pressure; increases in serum potassium and creatinine concentrations were small.
  
  
  CONCLUSIONS
  In a heart failure clinic staffed by nurse and pharmacist specialists, it is possible to achieve target doses of key therapeutic agents and improve symptoms without adversely affecting electrolytes or renal function.
authors.affiliation: Department of Cardiology St. Bartholomews and the London NHS Trust, London, United Kingdom.
authors.forename: Ajay
authors.initials: A
authors.lastname: Jain
authors.forename: Peter
authors.initials: P
authors.lastname: Mills
authors.forename: Laurence M
authors.initials: LM
authors.lastname: Nunn
authors.forename: Jane
authors.initials: J
authors.lastname: Butler
authors.forename: Lisa
authors.initials: L
authors.lastname: Luddington
authors.forename: Valerie
authors.initials: V
authors.lastname: Ross
authors.forename: Paraic
authors.initials: P
authors.lastname: Cliffe
authors.forename: Kulasagaram
authors.initials: K
authors.lastname: Ranjadayalan
authors.forename: Adam D
authors.initials: AD
authors.lastname: Timmis
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D011307:Drug Prescriptions / Q000706:statistics & numerical data; D004363:Drug Utilization; D005260:Female; D006333:Heart Failure / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009722:Nurse Practitioners; D010044:Outpatient Clinics, Hospital; D010348:Patient Care Team; D010595:Pharmacists; D013222:State Medicine; D006113:United Kingdom
chemical_list: D000319:Adrenergic beta-Antagonists; D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors