title: A nurse-led up-titration clinic improves chronic heart failure optimization of beta-adrenergic receptor blocking therapy--a randomized controlled trial.
abstract: BACKGROUND
  Beta-adrenergic blockade has been shown to improve left ventricular function, reduce hospital admissions and improve survival in chronic heart failure with reduced ejection fraction (HFrEF), with mortality reduction starting early after beta-adrenergic receptor blocker initiation and being dose-related. The aim of this pilot study was to determine the effectiveness of a nurse-led titration clinic in improving the time required for patients to reach optimal doses of the beta-adrenergic receptor blocking agents.
  
  
  METHODS
  We conducted a prospective pilot randomized controlled trial. Twenty eight patients with CHF were randomized to optimisation of beta-adrenergic receptor blocker therapy over six months by either a nurse-led titration (NLT) clinic, led by a nurse specialist with the support of a cardiologist in a CHF clinic, or by their primary care physician (usual care (UC)). The primary endpoint was time to maximal beta-adrenergic receptor blocker dose. The secondary end-point was the proportion of patients reaching the target dose of beta-adrenergic receptor blocker by six months.
  
  
  RESULTS
  The patients were predominantly men (72%), age 67 ± 16 years; New York Heart Association (NYHA) functional class I (32%), II (44%) and III (20%); baseline left ventricular ejection fraction 33 ± 10%, and a low mean Charlson co-morbidity score of 2.5 ± 1.4. The time to maximum dose was shorter in the NLT group compared to the UC group (90 ± 14 vs 166 ± 8 days, p < 0.0005). At six months, in the NLT group there were nine patients (82%) on high dose and one patient (9%) on low dose beta-adrenergic receptor blocker compared to the UC group with five (42%) patients reaching maximum dose and five (42%) patients on low dose (p = 0.04). The patients allocated to the NLT group also had significantly less worsening of depression between baseline and six months (p = 0.006).
  
  
  CONCLUSIONS
  A NLT clinic improves optimisation of beta-adrenergic receptor blocker therapy through increasing the proportion of patients reaching maximal dose and facilitating rapid up-titration of beta-adrenergic receptor blocker agents in patients with chronic HFrEF.
  
  
  BACKGROUND
  Australian Clinical Trials Registry (ACTRN012606000383561).
authors.affiliation: School of Nursing and Midwifery, Deakin University, 225 Burwood Highway, Melbourne, Burwood, Australia. andrea.driscoll@deakin.edu.au.
authors.forename: Andrea
authors.initials: A
authors.lastname: Driscoll
authors.forename: Piyush
authors.initials: P
authors.lastname: Srivastava
authors.forename: Deidre
authors.initials: D
authors.lastname: Toia
authors.forename: Jackie
authors.initials: J
authors.lastname: Gibcus
authors.forename: David L
authors.initials: DL
authors.lastname: Hare
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000368:Aged; D002908:Chronic Disease; D005260:Female; D006333:Heart Failure / Q000188:drug therapy* / Q000451:nursing; D006801:Humans; D008297:Male; D008875:Middle Aged; D057184:Practice Patterns, Nurses'; D011446:Prospective Studies
chemical_list: D000319:Adrenergic beta-Antagonists