NIHR Signal Specialist nurses can manage heart failure drug dosing successfully

Published on 9 February 2016

Use of specialist nurses to optimise drug dosages using protocols in people with heart failure was more effective than dose monitoring by other health professionals. These nurses had advanced practice certification. This finding came from a review of seven trials with more than 1600 patients.

International guidelines recommend two or three first-line medications for people with heart failure. These drugs (beta-adrenergic blocking agents, angiotensin converting enzyme inhibitors and angiotensin receptor blockers) can improve survival and are usually started at low doses by cardiologists and then gradually increased over time, a process managed between cardiologists and GPs. This can be a prolonged process because outpatient appointments may be infrequent and some GPs are reluctant to increase drug doses due to concerns about potential side effects. Using specialist nurses to optimise dosing in frequent outpatient appointments or home visits, through protocols and consultation with cardiologists, reduced deaths and hospital admissions. It is not clear how much this may have been due to the increased number and frequency of appointments, the protocols used or improved communication with the cardiology team.

Specialist nurse titration of drug dosing offers an effective and safe alternative way to deliver care to people with heart failure. No evidence was available on cost-effectiveness of these different approaches.

Specialist nurses can manage heart failure drug dosing successfully

Why was this study needed?

Heart failure means that the heart is not as effective as it normally would be. This can be due to problems with the heart muscle (such as weakening) or mechanical problems in the heart (such as damaged valves). Around 900,000 people in the UK have heart failure.

The outlook for people with heart failure can be very poor – 30 to 40% of people die within a year of diagnosis – so getting the condition under control is important. For people with mild to moderate heart failure, drug doses are largely managed by GPs. An Australian study found that GPs often didn’t prescribe high enough doses because they were worried about potential side effects and how they would interact with other medications.

This systematic review investigated whether specialist nurses using hospital protocols – rather than GPs – could safely and effectively manage the dose increases of first-line heart failure medicines to the optimal dosage and consult with cardiologists when required.

What did this study do?

This systematic review included seven randomised controlled trials (with a total of 1684 participants) comparing the management of drug doses by either nurses or another health professional. Included studies compared beta-adrenergic blocking agents, angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers.

The people included in the studies had heart failure caused by the left side of the heart not pumping as effectively as it should – left ventricular systolic dysfunction – which is also referred to as heart failure with reduced ejection fraction.

This systematic review was carried out to the usual high methodological standards of the Cochrane Collaboration.

What did it find?

  • Four out of seven studies (556 participants) examined all-cause hospital admissions. People in the nurse management group experienced a 20% lower rate of all-cause hospital admissions (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.72 to 0.88) and half the number of hospital admissions related to heart failure (RR 0.51, 95% CI 0.36 to 0.72) compared to the usual care group.
  • Six studies (902 participants) measured all-cause mortality, which was found to be 34% lower in the nurse management group (RR 0.66, 95% CI 0.48 to 0.92) than usual care. The authors calculated that 27 deaths could be avoided for every 1000 people receiving nurse managed dosing.
  • Three studies (370 participants) reported how long people were “event free” (e.g. without a flare up of their condition). People receiving nurse management were 40% more likely to remain event free compared to usual-care (RR 0.60, 95% CI 0.46 to 0.77).
  • Double the number of people reached the target dose of beta-adrenergic blocking agents in the nurse managed group (RR 1.99, 95% CI 1.61 to 2.47), according to five studies (966 participants), but there was a high risk of bias in these studies so the result may not be reliable.
  • People receiving nurse managed dosing reached the optimal dose of beta-adrenergic blocking agents in half the time of people receiving usual care.
  • Two studies investigated adverse events, one found that there were no adverse events, and the other did not specify the type or severity of the adverse event. So no firm conclusions could be drawn about potential harms.

What does current guidance say on this issue?

NICE’s 2010 guidance recommends that people with heart failure are first treated with angiotensin-converting enzyme (ACE) inhibitors and beta-blockers. Both drugs should be started on a low dose, gradually increased whilst carefully monitoring the person’s condition. NICE guidance does not specify who should manage people’s doses.

Angiotensin receptor blockers (ARBs) are only recommended if treatment with ACE inhibitors and beta-blockers has not been successful or the person experienced side effects from ACE inhibitors. Before starting ARBs, NICE recommends that GPs seek specialist advice.

What are the implications?

This systematic review demonstrates that specialist cardiology nurses and those designated as advanced practice nurses who titrate drug doses for heart failure patients is safe and highly effective. It is not clear how much this may have been due to the increased number and frequency of appointments, the protocols used or improved communication with the cardiology team.

A cost analysis was not included in this review. Managing people’s condition better and reducing complications (such as hospitalisation) could potentially reduce costs, although there will be set-up costs such as training nurses to the advanced standards required to prescribe medication, in addition to the costs of the extra nurse-led outpatient or home visits.  It is also possible that staff-substitution may be accompanied by higher costs, due to longer consultations or more frequent visits.

A 2015 nationwide survey found that 18.1% of people couldn’t get an appointment with their GP within a week. So transferring duties – where it is safe to do so – to other members of the team has the potential to ease pressure on GP appointments and in this case to deliver better care.

Bibliography

Donnelly L. Soaring numbers struggling with GP opening hours. The Telegraph. 17 January 2016.

NICE. Chronic heart failure in adults: management. CG108. London: National Institute for Health and Care Excellence; 2010.

Phillips SM, Marton RL, Tofler GH. Barriers to diagnosing and managing heart failure in primary care. Med J Aust. 2004;181(2):78-81.

Why was this study needed?

Heart failure means that the heart is not as effective as it normally would be. This can be due to problems with the heart muscle (such as weakening) or mechanical problems in the heart (such as damaged valves). Around 900,000 people in the UK have heart failure.

The outlook for people with heart failure can be very poor – 30 to 40% of people die within a year of diagnosis – so getting the condition under control is important. For people with mild to moderate heart failure, drug doses are largely managed by GPs. An Australian study found that GPs often didn’t prescribe high enough doses because they were worried about potential side effects and how they would interact with other medications.

This systematic review investigated whether specialist nurses using hospital protocols – rather than GPs – could safely and effectively manage the dose increases of first-line heart failure medicines to the optimal dosage and consult with cardiologists when required.

What did this study do?

This systematic review included seven randomised controlled trials (with a total of 1684 participants) comparing the management of drug doses by either nurses or another health professional. Included studies compared beta-adrenergic blocking agents, angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers.

The people included in the studies had heart failure caused by the left side of the heart not pumping as effectively as it should – left ventricular systolic dysfunction – which is also referred to as heart failure with reduced ejection fraction.

This systematic review was carried out to the usual high methodological standards of the Cochrane Collaboration.

What did it find?

  • Four out of seven studies (556 participants) examined all-cause hospital admissions. People in the nurse management group experienced a 20% lower rate of all-cause hospital admissions (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.72 to 0.88) and half the number of hospital admissions related to heart failure (RR 0.51, 95% CI 0.36 to 0.72) compared to the usual care group.
  • Six studies (902 participants) measured all-cause mortality, which was found to be 34% lower in the nurse management group (RR 0.66, 95% CI 0.48 to 0.92) than usual care. The authors calculated that 27 deaths could be avoided for every 1000 people receiving nurse managed dosing.
  • Three studies (370 participants) reported how long people were “event free” (e.g. without a flare up of their condition). People receiving nurse management were 40% more likely to remain event free compared to usual-care (RR 0.60, 95% CI 0.46 to 0.77).
  • Double the number of people reached the target dose of beta-adrenergic blocking agents in the nurse managed group (RR 1.99, 95% CI 1.61 to 2.47), according to five studies (966 participants), but there was a high risk of bias in these studies so the result may not be reliable.
  • People receiving nurse managed dosing reached the optimal dose of beta-adrenergic blocking agents in half the time of people receiving usual care.
  • Two studies investigated adverse events, one found that there were no adverse events, and the other did not specify the type or severity of the adverse event. So no firm conclusions could be drawn about potential harms.

What does current guidance say on this issue?

NICE’s 2010 guidance recommends that people with heart failure are first treated with angiotensin-converting enzyme (ACE) inhibitors and beta-blockers. Both drugs should be started on a low dose, gradually increased whilst carefully monitoring the person’s condition. NICE guidance does not specify who should manage people’s doses.

Angiotensin receptor blockers (ARBs) are only recommended if treatment with ACE inhibitors and beta-blockers has not been successful or the person experienced side effects from ACE inhibitors. Before starting ARBs, NICE recommends that GPs seek specialist advice.

What are the implications?

This systematic review demonstrates that specialist cardiology nurses and those designated as advanced practice nurses who titrate drug doses for heart failure patients is safe and highly effective. It is not clear how much this may have been due to the increased number and frequency of appointments, the protocols used or improved communication with the cardiology team.

A cost analysis was not included in this review. Managing people’s condition better and reducing complications (such as hospitalisation) could potentially reduce costs, although there will be set-up costs such as training nurses to the advanced standards required to prescribe medication, in addition to the costs of the extra nurse-led outpatient or home visits.  It is also possible that staff-substitution may be accompanied by higher costs, due to longer consultations or more frequent visits.

A 2015 nationwide survey found that 18.1% of people couldn’t get an appointment with their GP within a week. So transferring duties – where it is safe to do so – to other members of the team has the potential to ease pressure on GP appointments and in this case to deliver better care.

Bibliography

Donnelly L. Soaring numbers struggling with GP opening hours. The Telegraph. 17 January 2016.

NICE. Chronic heart failure in adults: management. CG108. London: National Institute for Health and Care Excellence; 2010.

Phillips SM, Marton RL, Tofler GH. Barriers to diagnosing and managing heart failure in primary care. Med J Aust. 2004;181(2):78-81.

Nurse-led titration of angiotensin converting enzyme inhibitors, beta-adrenergic blocking agents, and angiotensin receptor blockers for people with heart failure with reduced ejection fraction

Published on 23 December 2015

Driscoll, A.,Currey, J.,Tonkin, A.,Krum, H.

Cochrane Database Syst Rev Volume 12 , 2015

BACKGROUND: Heart failure is associated with high mortality and hospital readmissions. Beta-adrenergic blocking agents, angiotensin converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) can improve survival and reduce hospital readmissions and are recommended as first-line therapy in the treatment of heart failure. Evidence has also shown that there is a dose-dependent relationship of these medications with patient outcomes. Despite this evidence, primary care physicians are reluctant to up-titrate these medications. New strategies aimed at facilitating this up-titration are warranted. Nurse-led titration (NLT) is one such strategy. OBJECTIVES: To assess the effects of NLT of beta-adrenergic blocking agents, ACEIs, and ARBs in patients with heart failure with reduced ejection fraction (HFrEF) in terms of safety and patient outcomes. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL Issue 11 of 12, 19/12/2014), MEDLINE OVID (1946 to November week 3 2014), and EMBASE Classic and EMBASE OVID (1947 to 2014 week 50). We also searched reference lists of relevant primary studies, systematic reviews, clinical trial registries, and unpublished theses sources. We used no language restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing NLT of beta-adrenergic blocking agents, ACEIs, and/or ARBs comparing the optimisation of these medications by a nurse to optimisation by another health professional in patients with HFrEF. DATA COLLECTION AND ANALYSIS: Two review authors (AD & JC) independently assessed studies for eligibility and risk of bias. We contacted primary authors if we required additional information. We examined quality of evidence using the GRADE rating tool for RCTs. We analysed extracted data by risk ratio (RR) with 95% confidence interval (CI) for dichotomous data to measure effect sizes of intervention group compared with usual-care group. Meta-analyses used the fixed-effect Mantel-Haenszel method. We assessed heterogeneity between studies by Chi2 and I2. MAIN RESULTS: We included seven studies (1684 participants) in the review. One study enrolled participants from a residential care facility, and the other six studies from primary care and outpatient clinics. All-cause hospital admission data was available in four studies (556 participants). Participants in the NLT group experienced a lower rate of all-cause hospital admissions (RR 0.80, 95% CI 0.72 to 0.88, high-quality evidence) and fewer hospital admissions related to heart failure (RR 0.51, 95% CI 0.36 to 0.72, moderate-quality evidence) compared to the usual-care group. Six studies (902 participants) examined all-cause mortality. All-cause mortality was also lower in the NLT group (RR 0.66, 95% CI 0.48 to 0.92, moderate-quality evidence) compared to usual care. Approximately 27 deaths could be avoided for every 1000 people receiving NLT of beta-adrenergic blocking agents, ACEIs, and ARBs. Only three studies (370 participants) reported outcomes on all-cause and heart failure-related event-free survival. Participants in the NLT group were more likely to remain event free compared to participants in the usual-care group (RR 0.60, 95% CI 0.46 to 0.77, moderate-quality evidence). Five studies (966 participants) reported on the number of participants reaching target dose of beta-adrenergic blocking agents. This was also higher in the NLT group compared to usual care (RR 1.99, 95% CI 1.61 to 2.47, low-quality evidence). However, there was a substantial degree of heterogeneity in this pooled analysis. We rated the risk of bias in these studies as high mainly due to a lack of clarity regarding incomplete outcome data, lack of reporting on adverse events associated with the intervention, and the inability to blind participants and personnel. Participants in the NLT group reached maximal dose of beta-adrenergic blocking agents in half the time compared with participants in usual care. Two studies reported on adverse events; one of these studies stated there were no adverse events, and the other study found one adverse event but did not specify the type or severity of the adverse event. AUTHORS' CONCLUSIONS: Participants in the NLT group experienced fewer hospital admissions for any cause and an increase in survival and number of participants reaching target dose within a shorter time period. However, the quality of evidence regarding the proportion of participants reaching target dose was low and should be interpreted with caution. We found high-quality evidence supporting NLT as one strategy that may improve the optimisation of beta-adrenergic blocking agents resulting in a reduction in hospital admissions. Despite evidence of a dose-dependent relationship of beta-adrenergic blocking agents, ACEIs, and ARBs with improving outcomes in patients with HFrEF, the translation of this evidence into clinical practice is poor. NLT is one strategy that facilitates the implementation of this evidence into practice.

What did the nurses do?

The researchers describe a process where the nurse assesses the patient, reviews blood test results, and educates the patient and carer about heart failure. The heart failure nurse or nurse practitioner will then titrate the medication according to a predetermined protocol. Depending on hospital policy, the heart failure nurse may or may not consult with a cardiologist. In the home visit setting, similar processes are used. These nurses are advanced practice nurses and employed as a nurse practitioner or senior cardiac nurse. They must have institutional approval to titrate these medications.

None of the studies described the training undertaken by the heart failure nurses. In clinical practice, provided the nurses are already employed in an advanced practice role, no additional training is required.

Expert commentary

Pharmacological and device therapies have transformed the prognosis of heart failure secondary to left ventricular systolic dysfunction when delivered to the right patient, at the right time and at the right dose. However, titration of therapy requires time and effort. Failure to implement medicines safely and effectively seems almost inevitable unless there is a structured approach. A recently published Cochrane Systematic Review suggests that specialist nurses can titrate medicines more efficiently than standard practice, reducing morbidity and mortality substantially.

Alongside specialist nurse management, tele-monitoring may further improve the implementation of medical therapy for heart failure. Combining human skills with enabling technologies recruits the patient and informal carer to the health-care delivery team.

Professor John GF Cleland, National Heart & Lung Institute, Royal Brompton and Harefield Hospital, Imperial College, London

Expert commentary

One of the key roles undertaken by heart failure nurses relates to the up-titration of key medication. There is considerable evidence to support the use of ACEI, ARB and beta-adrenergic blocking drugs in heart failure and this review gives some support to nurse-led titration of these drugs. The review recognised that the evidence regarding patient numbers reaching target dose was low and suggested room for improvement. Also, the increasingly common concomitant use of aldosterone antagonists was not described. However, those in the nurse-led titration did better (in terms of morbidity and mortality). This strategy should be encouraged as a means of supporting patients in having dose-appropriate heart failure medication. Providing appropriate numbers of specialist nurses should remain a priority in the delivery of heart failure care.

Dr Gethin Ellis, Consultant Cardiologist, Cwm Taf University Health Board

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