scholarly journals Heart Failure Prescribing Quality at Discharge from a Critical Care Unit in Egypt: The Impact of Multidisciplinary Care

Pharmacy ◽  
2020 ◽  
Vol 8 (3) ◽  
pp. 159
Author(s):  
Seif El Hadidi ◽  
Naglaa Samir Bazan ◽  
Stephen Byrne ◽  
Ebtissam Darweesh ◽  
Margaret Bermingham
Keyword(s):  
Heart Failure ◽  
Critical Care ◽  
Guideline Adherence ◽  
Clinical Pharmacist ◽  
Critical Care Unit ◽  
Angiotensin Receptor Blockers ◽  
Multidisciplinary Care ◽  
Converting Enzyme Inhibitors ◽  
The Impact ◽  
Adherence Index

Discharge prescriptions for heart failure (HF) patients may not adhere to the clinical practice guidelines. This study aimed to assess the impact of the clinical pharmacist as a member of a multidisciplinary team on the quality of prescribing to HF patients at discharge from a Critical Care Unit (CCU) in Egypt. This was a retrospective cohort study of HF patients discharged from the CCU between January 2013 and December 2017. Guideline Adherence Index (GAI-3) was used to assess guideline-directed prescribing at discharge. Multidisciplinary care was introduced to the CCU on 1 January 2016. The study included 284 HF patients, mean (±SD) age 66.7 ± 11.5 years, 53.2% male. Heart failure with reduced ejection fraction affected 100 patients (35.2%). At discharge, loop diuretics were prescribed to 85.2% of patients; mineralocorticoid receptor antagonists to 54.9%; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers to 51.4%; and β-blockers to 29.9%. Population Guideline Adherence Index (GAI-3) was 45.5%. High-GAI was prescribed to 136 patients (47.9%). Patients with High-GAI were younger; less affected by chronic kidney disease and had fewer comorbidities than those without High-GAI. Prescription of β-blocker increased (24.1% vs. 38.6%, p < 0.001) and digoxin utilization decreased (34.7% vs. 23.7%, p < 0.049) after the introduction of the multidisciplinary care. The inclusion of a clinical pharmacist in the multidisciplinary care team may have a role in optimizing the prescribing of HF guideline-directed therapies at discharge from this setting.

P783Guideline-directed therapy at discharge is important in patients with heart failure and atrial fibrillation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
B S Yoo ◽  
M S Ahn ◽  
S J Lee ◽  
J W Son ◽  
J Y Kim ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Ejection Fraction ◽  
Beneficial Effect ◽  
Clinical Outcomes ◽  
Guideline Adherence ◽  
Angiotensin Receptor Blockers ◽  
Composite Endpoint ◽  
Converting Enzyme Inhibitors ◽  
Reduced Ejection Fraction

Abstract Background There are limited and conflicting data regarding the prognostic implication of guideline-directed therapy, especially in heart failure (HF) patients with atrial fibrillation (AF). Thus, this study evaluated the relationship between guideline adherence to recommended therapy at discharge and relevant 60-day clinical outcomes in acute HF patients with AF having reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF). Methods and results Of 5,625 acute HF patients in the Korean Acute Heart Failure Registry, 2,071 with documented AF (HFrEF, n=986; HFpEF, n=1,085) were separately analysed. A guideline adherence score was calculated for the prescription of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, mineralocorticoid receptor antagonists, and anticoagulants. In HFrEF patients with AF, there was significant trend of increase in mortality (p for trend <0.001) and composite endpoint (p for trend = 0.002) according to guideline adherence. Poor adherence was associated with a significantly high risk of mortality (hazard ratio [HR], 4.75; 95% confidence interval [95% CI], 1.77–12.74) and composite endpoint (HR, 2.36; 95% CI, 1.33–4.18). In HFpEF patients with AF, there was a significant increasing trend for rehospitalization (p for trend = 0.04) and composite endpoint (p for trend = 0.03). However, the beneficial effect of good guideline adherence was statistically non-significant for all clinical outcomes Conclusion Better adherence to guidelines was associated with a better 60-day prognosis in both HFrEF and HFpEF patients with AF. However, the beneficial effect of guideline adherence was more pronounced in HFrEF patients with AF.

Impact of Clinical Audit on Adherence to the Guidelines Directed Medical Therapy in Patients Admitted with Heart Failure

2020 ◽  
Vol 15 (2) ◽  
pp. 117-123
Author(s):  
Aashiq A. Shukkoor ◽  
Nimmy E. George ◽  
Shanmugasundaram Radhakrishnan ◽  
Sivakumar Velusamy ◽  
Tamilarasu kaliappan ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Acute Heart Failure ◽  
Medical Therapy ◽  
Clinical Audit ◽  
Angiotensin Receptor Blockers ◽  
Angiotensin Receptor ◽  
Converting Enzyme Inhibitors ◽  
Reduced Ejection Fraction ◽  
The Impact

Background: The adoption of guideline recommendations of pharmacotherapy to improve the clinical course of Heart Failure (HF) remains below par. Our objective is to evaluate the impact of clinical audit on adherence to the Guideline-Directed Medical Therapy (GDMT) in patients admitted with acute heart failure with reduced ejection fraction (EF). Methods: A prospective interventional study was conducted over a period of 12 months from June 2018 to May 2019 in all patients admitted with acute heart failure with reduced ejection fraction. The discharge prescriptions of patients who met the inclusion criteria were audited for appropriateness in the usage of neurohormonal blockers and Ivabradine, by a clinical pharmacist on a monthly basis. Audit results were presented to the practicing physicians every month and feedback was given. Results: Discharge prescriptions of 716 patients who presented with HF were audited for the reasonable or unreasonable omission of neurohormonal blocking drugs. The first-month audit revealed that the unreasonable omission of Angiotensin-Converting Enzyme Inhibitors/ Angiotensin Receptor Blockers/ Angiotensin Receptor Neprilisin Inhibitors ( ACEI/ARB/ARNI), Betablockers and Mineralocorticoid Receptor Antagonists (MRA) were 24.5%, 13.1%, and 9.09% respectively, which reduced to nil at the end of the study period (p=0.00). Initiation of Ivabradine before prescribing or achieving the target dose of Betablocker was noted in 38.18% of patients in the first month, which was also reduced to nil (p=0.00) at the end of the study. Conclusion: This study reveals that periodic clinical audit improves adherence to GDMT in patients admitted with heart failure with reduced ejection fraction.

The Impact of Transitions of Care Pharmacist Services and Identification of Risk Predictors in Heart Failure Readmission

2019 ◽  
pp. 089719001988417 ◽  
Author(s):  
Marci Wood ◽  
Tracey Sweeney ◽  
Molly Trayah ◽  
Maria Civalier ◽  
Wesley McMillian
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Angiotensin Receptor Blockers ◽  
Significant Risk ◽  
Retrospective Chart Review ◽  
Transitions Of Care ◽  
Converting Enzyme Inhibitors ◽  
Increased Risk ◽  
Risk Predictors ◽  
The Impact

Background: Heart failure (HF) is a prevalent and costly disease state for adult Americans, with 30-day readmissions rates for patients with HF utilized to limit hospital compensation. Objective: To determine the impact of the transitions of care (TOC) service at our institution on 30-day all-cause and HF readmissions and identify predictive risk factors for 30-day all-cause readmission. Methods: Retrospective chart review of patients aged 18 years and older admitted with HF and all subsequent readmissions between October 1, 2015, and September 30, 2017. A weighted logistic regression model was developed to determine risk factors for 30-day all-cause readmission. Results: There were no significant differences in all-cause or HF readmission rates analyzed by TOC service involvement. Significant risk predictors for 30-day all-cause readmission included discharge to a rehabilitation facility (odds ratio [OR] = 9.3) or home with home health (OR = 1.6) versus home with self-care. Comorbidities associated with an increased risk of 30-day all-cause readmission included diabetes, coronary artery disease, and aortic stenosis. Use of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and spironolactone was associated with decreased risk of 30-day all-cause readmission. Conclusion: Identified predictors in the patient population with HF at our institution may be used to target patients at increased risk of all-cause readmission within 30 days.

scholarly journals Evaluation of the prescribing practice of guideline-directed medical therapy among ambulatory chronic heart failure patients

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Daya Ram Parajuli ◽  
Sepehr Shakib ◽  
Joanne Eng-Frost ◽  
Ross A. McKinnon ◽  
Gillian E. Caughey ◽  
...  
Keyword(s):  
Heart Failure ◽  
Medical Therapy ◽  
Best Practice ◽  
Angiotensin Receptor Blockers ◽  
Multidisciplinary Care ◽  
Chronic Atrial Fibrillation ◽  
Careful Consideration ◽  
Prescribing Practices ◽  
Converting Enzyme Inhibitors ◽  
Retrospective Audit

Abstract Background Studies have demonstrated that heart failure (HF) patients who receive direct pharmacist input as part of multidisciplinary care have better clinical outcomes. This study evaluated/compared the difference in prescribing practices of guideline-directed medical therapy (GDMT) for chronic HF patients between two multidisciplinary clinics—with and without the direct involvement of a pharmacist. Methods A retrospective audit of chronic HF patients, presenting to two multidisciplinary outpatient clinics between March 2005 and January 2017, was performed; a Multidisciplinary Ambulatory Consulting Service (MACS) with an integrated pharmacist model of care and a General Cardiology Heart Failure Service (GCHFS) clinic, without the active involvement of a pharmacist. Results MACS clinic patients were significantly older (80 vs. 73 years, p < .001), more likely to be female (p < .001), and had significantly higher systolic (123 vs. 112 mmHg, p < .001) and diastolic (67 vs. 60 mmHg, p < .05) blood pressures compared to the GCHF clinic patients. Moreover, the MACS clinic patients showed more polypharmacy and higher prevalence of multiple comorbidities. Both clinics had similar prescribing rates of GDMT and achieved maximal tolerated doses of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in HFrEF. However, HFpEF patients in the MACS clinic were significantly more likely to be prescribed ACEIs/ARBs (70.5% vs. 56.2%, p = 0.0314) than the GCHFS patients. Patients with both HFrEF and HFpEF (MACS clinic) were significantly less likely to be prescribed β-blockers and mineralocorticoid receptor antagonists. Use of digoxin in chronic atrial fibrillation (AF) in MACS clinic was significantly higher in HFrEF patients (82.5% vs. 58.5%, p = 0.004), but the number of people anticoagulated in presence of AF (27.1% vs. 48.0%, p = 0.002) and prescribed diuretics (84.0% vs. 94.5%, p = 0.022) were significantly lower in HFpEF patients attending the MACS clinic. Age, heart rate, systolic blood pressure (SBP), anemia, chronic renal failure, and other comorbidities were the main significant predictors of utilization of GDMT in a multivariate binary logistic regression. Conclusions Lower prescription rates of some medications in the pharmacist-involved multidisciplinary team were found. Careful consideration of demographic and clinical characteristics, contraindications for use of medications, polypharmacy, and underlying comorbidities is necessary to achieve best practice.

scholarly journals Evaluation of demographic, clinical characteristics, and the prescribing practice of guideline-directed medical therapy among chronic heart failure outpatients in multidisciplinary clinics in a large tertiary hospital: a retrospective audit of 1186 patients from 12 years

2020 ◽  
Author(s):  
Daya Ram Parajuli ◽  
Sepehr Shakib ◽  
Joanne Eng-Frost ◽  
Ross McKinnon ◽  
Gillian Caughey ◽  
...  
Keyword(s):  
Heart Failure ◽  
Chronic Heart Failure ◽  
Ejection Fraction ◽  
Medical Therapy ◽  
Multidisciplinary Team ◽  
Angiotensin Receptor Blockers ◽  
Multidisciplinary Care ◽  
Tertiary Hospital ◽  
Converting Enzyme Inhibitors ◽  
Retrospective Audit

Abstract BackgroundAdherence to guideline-directed medical therapy (GDMT) remains low particularly in elderly despite several approaches. Previous studies showed that heart failure (HF) patients who receive pharmacist-involved multidisciplinary care may have better clinical outcomes. We evaluated patient characteristics and the practice of receiving individual GDMT in chronic HF patients who attended multidisciplinary clinics.MethodsA retrospective audit of data of chronic HF patients presenting to two multidisciplinary outpatient clinics at a tertiary hospital between March 2005 and January 2017 was performed. Data were obtained from two clinics, a Multidisciplinary Ambulatory Consulting Service (MACS) clinic which uses a pharmacist-involved model of multidisciplinary care, and a General Cardiology Heart Failure Service (GCHFS) clinic which does not have the active involvement of a pharmacist.ResultsHF with mid-range ejection fraction (HFmrEF) subjects resembled the HF with preserved ejection fraction (HFpEF) patients in terms of age, heart rate (HR), systolic blood pressure (SBP) and having higher prevalence of polypharmacy whereas resembled with the HF with reduced ejection fraction (HFrEF) for the proportion of male distribution and prevalence of ischemic heart disease (IHD). Both the clinics had similar prescribing rates of GDMT and achieved maximal tolerated doses of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARB) in HFrEF, but significantly higher prescription of ACEIs/ARBs (70.5% v. 56.2%) was found in HFpEF patients in the MACS clinic. There was significantly lower rates of β-blockers and mineralocorticoid receptor antagonists (MRAs) prescription in HFrEF and HFpEF patients in both clinics. Use of digoxin in chronic atrial fibrillation (AF) was significantly higher in HFrEF patients (82.5% v. 58.5%), but number of people anticoagulated in presence of AF and prescription of diuretics were significantly lowered in MACS clinic in HFpEF patients. Age, anemia, chronic renal failure, SBP, HR and comorbidities were the significant predictors in a multivariate binary logistic regression for the utilization of GDMT.ConclusionsOur study concludes that pharmacist is an important member of a multidisciplinary team in the management of chronic heart failure. The other roles of the pharmacist within a multidisciplinary team, including continuity of care, medication compliance and prevention of adverse reactions need further research.

scholarly journals Control of blood pressure and cardiovascular outcomes in type 2 diabetes

Open Medicine ◽  
2018 ◽  
Vol 13 (1) ◽  
pp. 304-323 ◽  
Author(s):  
Hernando Vargas-Uricoechea ◽  
Manuel Felipe Cáceres-Acosta
Keyword(s):  
Blood Pressure ◽  
Cardiovascular Events ◽  
Angiotensin Receptor Blockers ◽  
Pharmacological Therapy ◽  
Current Evidence ◽  
Diabetic Patients ◽  
Channel Blockers ◽  
Converting Enzyme Inhibitors ◽  
Patients With Diabetes ◽  
The Impact

AbstractHigh blood pressure in patients with diabetes mellitus results in a significant increase in the risk of cardiovascular events and mortality. The current evidence regarding the impact of intervention on blood pressure levels (in accordance with a specific threshold) is not particularly robust. Blood pressure control is more difficult to achieve in patients with diabetes than in non-diabetic patients, and requires using combination therapy in most patients. Different management guidelines recommend initiating pharmacological therapy with values >140/90 mm/Hg; however, an optimal cut point for this population has not been established. Based on the available evidence, it appears that blood pressure targets will probably have to be lower than <140/90mmHg, and that values approaching 130/80mmHg should be recommended. Initial treatment of hypertension in diabetes should include drug classes demonstrated to reduce cardiovascular events; i.e., angiotensin converting-enzyme inhibitors, angiotensin receptor blockers, diuretics, or dihydropyridine calcium channel blockers. The start of therapy must be individualized in accordance with the patient's baseline characteristics, and factors such as associated comorbidities, race, and age, inter alia.

scholarly journals The associations between direct and delayed critical care unit admission with mortality and readmissions among patients with heart failure

2021 ◽  
Vol 233 ◽  
pp. 20-38
Author(s):  
Ismail R. Raslan ◽  
Heather J. Ross ◽  
Robert A. Fowler ◽  
Damon C. Scales ◽  
Henry T. Stelfox ◽  
...  
Keyword(s):  
Heart Failure ◽  
Critical Care ◽  
Critical Care Unit ◽  
Patients With Heart Failure

Abstract 301: Identifying Critical Care Unit Organizational Factors That Impact Cardiac Arrest Incidence and Outcomes: A Report From the Pediatric Cardiac Critical Care Consortium

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Javier J Lasa ◽  
Jeffrey A Alten ◽  
Mousumi Banerjee ◽  
Wenying Zhang ◽  
Kurt Schumacher ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Critical Care ◽  
Critical Care Unit ◽  
Organizational Factors ◽  
Full Time ◽  
Provider Education ◽  
Multinomial Regression ◽  
Clinical Registry ◽  
The Impact ◽  
Cardiac Critical Care

Introduction: Patient factors leading to cardiac arrest (CA) in the pediatric cardiac critical care unit (CICU) are well understood, but may be unmodifiable. Our understanding of the impact of CICU organizational factors (OFs) such as staffing models, health care provider education, and CICU bed management is limited. The association between these potentially modifiable CICU OFs on CA prevention and rescue outcomes is unknown. Hypothesis: CICU OFs associate with CA prevention and rescue. Methods: Retrospective analysis of Pediatric Cardiac Critical Care Consortium (PC4) clinical registry including data for all patients admitted to CICUs from August 2014 to March 2019. Prevention was defined as the prevalence of subjects not suffering CA. Rescue was defined as survival after CA. CICU OFs were captured via questionnaire distributed to PC4 participants in 2017 (100% response). Stratified, multivariable regression was used to evaluate associations between OFs and outcome in medical and surgical admission subgroups: competing time-to-events framework (to assess prevention) and multinomial regression (to assess rescue), accounting for clustering of patients within hospitals. Results: We analyzed 54,521 CICU admissions (59% surgical, 41% medical) from 29 hospitals with 1398 CA events (2.5%). We studied 12 OFs that varied across centers after accounting for collinearity. For both surgical and medical admissions, lower average daily occupancy (<80%) was associated with better arrest prevention for all admissions, and better rescue in the surgical cohort. Increased proportion of nurses with >2 years experience, increased proportion of nurses with critical care certification, % of full-time intensivists, % of intensivists with critical care training, dedicated respiratory therapists, quality/safety resources, and annual CICU admission volume were not associated with improved prevention or rescue. Conclusion: Our multi-institutional analysis suggests that lower average CICU occupancy was the only consistent OF evaluated that was associated with CA prevention and rescue. CICUs that have average daily occupancy >80% may need specific strategies to mitigate the risks of CA.

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