Pharmacist-led rapid uptitration clinic in heart failure patients with reduced ejection fraction: Our experience within a virtual ward

Heart failure with reduced ejection fraction is a chronic, progressive medical condition affecting millions of individuals worldwide. It is associated with high morbidity and mortality. The use of “foundational quadruple therapy” titrated to the maximum tolerated doses improves survival, quality of life, and reduces heart failure-related hospitalisation. Despite this evidence, there is a consistent trend of suboptimal dose up-titration, prolonged optimisation periods, and early therapy discontinuation. Virtual wards offer a potential innovative solution in transforming heart failure management by combining rapid medication optimisation with remote monitoring to improve patient outcomes. This retrospective study employed a single-group pre-post design to evaluate the effectiveness of a prescribing pharmacist in the rapid uptitration of Guidelines Directed Medical Therapy (GDMT) in patients with heart failure with reduced ejection fraction within a virtual ward setting. The study assessed clinical outcomes of 86 patients at baseline, following discharge from the virtual ward (typically after 4 weeks), and at 3–6 months post-discharge. Improvements were seen in NYHA scores, cardiac systolic function, and Optimal Medical Therapy (OMT) scores. The median Left Ventricular Ejection Fraction increased from 29% at baseline to 39% post-optimisation, signifying improved myocardial performance and a reduction in the severity of left ventricular dysfunction. Post-optimisation, 37% of patients attained an optimal OMT score of 8, 52% attained an acceptable score (5–7), and only 5% remained in the suboptimal range (0–4). Additionally, 84% of patients were prescribed all four foundational therapies. There was no notable increase in adverse events such as hypotension, bradycardia, or hyperkalaemia. Remote up-titration of heart failure medications within a virtual ward environment is a promising approach, offering a fast, feasible, safe, and efficient treatment solution for patients who are otherwise undertreated.Author summary: Heart failure with reduced ejection fraction (HFrEF) occurs when the heart is unable to pump blood efficiently throughout the body, leading to symptoms like fatigue, shortness of breath, and fluid retention. Clinical guidelines worldwide recommend starting medical therapy as early as possible, adjusted to the highest tolerated doses, to avoid worsening of symptoms and emergency hospitalisation. However, this process requires frequent clinician reviews and close monitoring, making it time-consuming for both patients and healthcare providers thus leading to suboptimal doses and early discontinuation of therapy. The STRONG-HF study demonstrated that accelerated dose adjustments, paired with regular follow-up, not only improved heart failure symptoms and quality of life of patients but also significantly reduced hospital admission and death, highlighting the knowledge gap in treatment optimisation strategies. Virtual wards offer an innovative solution allowing patients to be monitored remotely at home while still receiving the necessary dose adjustments and clinical care. In this paper, we share our experience in implementing this pathway, which has allowed us to start treatment early and seamlessly adjust medication doses in accordance with patient-specific parameters leading to an improvement in heart function, New York Heart Association (NYHA) score, and a reduction in heart failure related hospitalisation.