Telephone titration of heart failure medications.
BACKGROUND
In clinical practice, heart failure (HF) medications are underused and prescribed at lower than recommended doses. Telephone care is an option that could help to titrate HF medication in a timely manner. We describe our experience of a nurse-run, cardiologist- or nurse practitioner-supervised clinic to up-titrate HF medications via telephone.


METHODS
Patients with the diagnosis of HF, New York Heart Association classes I to III, were referred to a registered nurse-run, cardiologist-/nurse practitioner-supervised HF medication titration clinic. Clinical and medication data collected at enrollment to the clinic and at 3 to 6 months after optimization of HF medications in patients who did or did not reach the target doses were compared. Effect on left ventricular (LV) function was also evaluated.


RESULTS
There were 79 patients in the evaluation: 64 with HF and LV systolic dysfunction (LVSD) and the remaining 15 with HF and preserved ejection fraction (EF). Seventy-two percent of patients with LVSD were on an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), and 61% were on a β-blocker at baseline, and this increased to 98% and 97%, respectively, after optimization. Target doses was achieved in 50% of patients for ACEI or ARB, and in 41% for β-blockers. The median time to optimization was 54 days (interquartile range, 20-97 days). The average number of phone calls at the time of optimization were 5.4 (SD, 3.7), and the average number of clinic visits was 1.9 (SD, 1.3). Reasons for not reaching the target doses included hypotension, hyperkalemia, and renal dysfunction for ACEI and bradycardia for β-blockers. Overall, the EF increased by 10% (SD, 10%) after 6 months, and 35% or greater in 42% of patients whose baseline EF was less than 35%. There were no adverse events related to the dose up-titration.


CONCLUSIONS
Telephonic titration of HF medications was feasible and safe and was achieved in 97% patients on ACEI/ARB and β-blockers. Medication titration was associated with significant improvement in LV function, avoiding the need for device therapy in many patients.
Anne E. Steckler, RN Registered Nurse, CHF TeleHealth Clinic, VA Medical Center, Minneapolis, Minnesota. Kalkidan Bishu, MD Resident in Internal Medicine, VA Medical Center, Minneapolis, Minnesota. Heba Wassif, MD Staff Physician, VA Medical Center, Minneapolis, Minnesota. Gardar Sigurdsson, MD Staff Physician, VA Medical Center, Minneapolis, Minnesota. Judy Wagner, NP Nurse Practitioner, CHF TeleHealth Clinic, VA Medical Center, Minneapolis, Minnesota. Connie Jaenicke, NP Nurse Practitioner, CHF TeleHealth Clinic, VA Medical Center, Minneapolis, Minnesota. Shashank Vats, MD Resident in Internal Medicine, VA Medical Center, Minneapolis, Minnesota. Thomas Rector, PhD Research Specialist, VA Medical Center, Minneapolis, Minnesota. Inder S. Anand, MD, DPhil (Oxon), FRCP Professor of Medicine, University of Minnesota Medical School, and Director, Heart Failure Program, VA Medical Center, Minnesota.
Anne E
AE
Steckler
Kalkidan
K
Bishu
Heba
H
Wassif
Gardar
G
Sigurdsson
Judy
J
Wagner
Connie
C
Jaenicke
Shashank
S
Vats
Thomas
T
Rector
Inder S
IS
Anand
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D064646:Cardiovascular Nursing / Q000379:methods* / Q000458:organization & administration; D003376:Counseling; D005260:Female; D006333:Heart Failure / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D055817:Telenursing; D013689:Telephone
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors