Effectively managing heart failure requires a multidisciplinary, holistic approach attuned to many factors: diagnosis of structural and functional cardiac abnormalities; medication, device, or surgical management; concomitant treatment of comorbidities; physical rehabilitation; dietary considerations; and social factors. This practice paper highlights the pharmacist's role in the management of patients with heart failure, the evidence supporting their functions, and steps to ensure the pharmacist resource is available to the broad population of patients with heart failure.
Managing Evidence-Based Polypharmacy and Therapy Optimization
Clinical research conducted over the last several decades has firmly established the evidence base for the pharmacologic management of heart failure. Drug therapy for chronic heart failure centers predominantly around angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB), beta-adrenergic blockers, mineralocorticoid receptor antagonists (MRA), hydralazine and isosorbide dinitrate (in African American patients), and more recently, the angiotensin receptor neprilysin inhibitor (ARNI) sacubitril/valsartan and ivabradine. Diuretics remain a component of the regimen for symptomatic relief, and digoxin may also be prescribed.
Polypharmacy generally carries a negative connotation, but in the case of heart failure, this evidence-based polypharmacy results in prolonged survival and reduced morbidity (i.e., hospitalizations). However, these regimens are complex and can be difficult to manage, especially without dedicated systems in place to monitor patient response and potential adverse effects. Pharmacists can easily assume this role, and their ability in general to promote the safe use of drugs and reduce medication prescribing errors has been recognized by the Institute of Medicine. Specific to managing heart failure, while each guideline-recommended drug class targets a specific component of heart failure pathophysiology, the pharmacodynamic effects of some agents are similar (e.g., ACE-inhibitors, ARBs, beta blockers, ARNI all lower blood pressure; ACE-inhibitors, ARBs, MRAs, ARNI raise serum potassium). Pharmacists, with their knowledge of clinical pharmacology, pharmacokinetics and pharmacogenomics, can design dosing regimens suitable for a given patient’s presentation and achieve goal evidence-based therapies for most patients. Specific strategies may be considered to permit optimization of all Guideline Directed Medical Therapies (GDMT).
Pharmacists also play an important role in the medical team managing patients with acute heart failure. They may contribute knowledge regarding precipitating factors (e.g. non- adherence to therapies, intake of drugs that may worsen heart failure) and can suggest dosing adjustments that may be necessary in light of changing renal or hepatic function. Pharmacists may also effectively monitor patient response to intravenous therapies. The pharmacist’s knowledge of drug dosing, pharmacokinetics, and drug interactions is a unique contribution to the cardiac transplantation or mechanical circulatory support teams, where managing immunosuppressive, anti-thrombotic, and anti-infection agents can be highly complex.
Comorbidities and Contraindicated Medications
Most patients with heart failure have comorbidities, including diabetes mellitus, hypertension, hyperlipidemia, atrial fibrillation, depression, or others, which also involve drug therapy. Thus, the number of daily drugs (and doses) prescribed for patients with heart failure can quickly accumulate. The potential for drug-drug interactions (pharmacokinetic or pharmacodynamic) also increases, and pharmacists are well positioned to advise prescribers on which drugs are contraindicated in combination, or when dose adjustments are necessary to account for drug-drug interactions. Drug-disease interactions can also occur; some drugs prescribed to treat comorbidities can exacerbate heart failure. Avoiding such drugs is also an area of focus for pharmacists involved in heart failure management. Notably for over-the- counter or complementary and alternative therapies, pharmacists may be the first point of contact for patients, are often the most accessible health care provider, and can play a vital role in the avoidance of drugs that may worsen heart failure.
Patient Education and Follow-up
Education is a key factor in improving patient adherence to chronic therapies. Pharmacist-provided patient education improves medication adherence and reduces adverse events and medication errors. Patients view pharmacists as approachable and accessible health-care providers, which facilitates patient engagement and can be a critical factor to the success of any intervention aiming to improve adherence. Drug-specific education, in language understandable to the patient, should be provided such that patients achieve an understanding of the purpose of each drug within their regimen, how to take it safely, potential adverse effects, and best approaches to managing side effects should they occur. Patients should be routinely queried about adherence in a non-judgmental manner; pharmacists may help in identifying sources of non-adherence (e.g., inability to afford the medication, adverse effects, regimen complexity, physical or cognitive impairment) and resolving the causes when possible (e.g., facilitating applications for medication assistance programs, adjusting doses, splitting tablets for some drugs where release properties will not be impacted, or suggesting less expensive alternatives such as generic equivalents when appropriate). Many approaches to improving adherence are available (e.g., direct education, electronic reminders, daily/weekly pill boxes, mobile health applications), and pharmacists should tailor adherence interventions to meet the needs of individual patients.
EVIDENCE SUPPORTING THE ROLE OF PHARMACISTS IN HEART FAILURE CARE
Studies involving pharmacists in the management of heart failure have been conducted, and the totality of evidence supports a clinical benefit of integrating pharmacists in the routine care of patients with heart failure. A systematic review of 12 randomized controlled trials involving 2,060 patients from countries around the world (i.e., Northern Ireland, the Netherlands, Canada, United Arab Emirates, United Kingdom, Spain, United States, Australia), designed either as pharmacists providing direct care or in collaboration with the heart failure management team, showed a reduction in the rate of all-cause hospitalizations (assessed in 11 trials, OR 0.71, 95% CI 0.54-0.94) and heart failure hospitalizations (assessed in 11 trials, OR 0.69, 95% CI 0.51-0.94) with pharmacist collaborative care, although there was no effect on all-cause mortality (OR 0.84, 95% CI 0.61-1.15).
Several professional societies have endorsed the integration of pharmacists in the management of patients with cardiovascular disease, with an emphasis on heart failure. The American College of Cardiology Foundation and the Heart Failure Society of America advocated a role for pharmacists in many of the activities described above, including drug therapy monitoring, drug interaction screening, drug and disease management, medication safety monitoring and patient education. The European Society of Cardiology heart failure guidelines recommends a multidisciplinary approach, including pharmacists, for the management of patients with heart failure. Pharmacists who provide heart failure care should have the requisite skills and knowledge to function in this capacity. Education, sub-specialty post- graduate training, and other credentials have been detailed elsewhere; maintaining current knowledge of clinical trial results and practice guidelines should also be emphasized.
APPLICATION IN PRACTICE
Pharmacists may fulfill the roles noted above in a variety of settings depending on local standards and regulations in their regions of practice, including but not limited to outpatient pharmacies, ambulatory clinics, assisted living or long-term care facilities, telemedicine management centers, and inpatient hospitals (general ward, step-down, or critical care). Pharmacists may be a member of the team responsible for providing primary heart failure care or function as an independent practitioner who performs consultations for the primary team. Although evidence and professional society endorsement supports the integration of pharmacists in the management of patients with heart failure, this model remains underutilized. Direct reimbursement for the provision of clinical services is a major impediment to the broader enactment of clinical pharmacists in the management of patients with heart failure. Resolving this issue is complex because pharmacists are not recognized as providers on a federal level. However, pharmacists can bill for services related to Medication Therapy Management, and evolving programs within Medicare or accountable care organizations may provide additional opportunities for reimbursement for pharmacist clinical activities. In addition to the reimbursement hurdle, there is no single model for the services a clinical pharmacist may provide, which may discourage private physician practices or smaller hospitals who are uncertain about implementation. Collaborative practice agreements between pharmacists and physicians are useful to define the role of the pharmacist, but standards for these agreements vary significantly across states, which also contributes to the inconsistent utilization of clinical pharmacy services for the management of patients with heart failure.
Despite the barriers, pharmacist involvement in the care of patients with heart failure has significantly expanded over the past 2 decades. Professional cardiology societies (e.g., American Heart Association, American College of Cardiology, Heart Failure Society of America) are increasingly becoming multidisciplinary. Pharmacists play prominent roles in councils and committees charged with advancing the care of patients with cardiovascular disease as a whole, and heart failure specifically, as evidenced by the publication of several key position papers. Continued advocacy at the local, state, and federal levels will permit more comprehensive uptake of clinical pharmacy services for the provision of heart failure care.
結論最後に、Considerable advances have been realized in the integration of clinical pharmacy services into heart failure management, and efforts should continue to achieve broader penetration of clinical pharmacists as vital members of the heart failure management team.と今後の願いが述べられています。