Methods:

This was a quality improvement project that included patients with HF with reduced ejection fraction (HFrEF) and HF with midrange EF. The GDMT optimization program was developed as a collaboration between NPs and pharmacists who specialized in HF. Data were collected between September 2020 and April 2023. A stepwise guideline was developed to initiate and titrate each drug class predicated on the guideline recommendation by 2017 and 2022 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Failure Society of America (HFSA) HF guidelines. Adjustments were made in the stepwise guidelines to allow for patient response to medication, nonadherence to follow-up blood draws, and pending approval of prescription assistance for novel medications (angiotensin receptor-neprilysin inhibitor [ARNi] and sodium glucose cotransporter 2 inhibitor [SGLT2i]). Patients were referred to the program by an HF provider. Patients were educated on the program process, medication side effects, routine blood work, and self-monitoring of weight, blood pressure (BP), and heart rate (HR). The HF NP and pharmacist managed the patient’s GDMT.

The pharmacist called the patient every 2 weeks, and relayed the patient’s BP, HR, and weight to the NP. The NP would respond with a decision regarding medication changes. Beta-blockers (BBs) and ARNi took precedence, followed by addition of SGLT2i and mineralocorticoid receptor antagonists (MRAs). GDMT was adjusted based on kidney function and patient vital signs. SGLT2i were started before MRAs to reduce incidence of hyperkalemia. Diuretic therapy was adjusted based on volume status, especially with the addition of ARNi and SGLT2i. Medications were adjusted one or two at a time depending on BP and HR. Carvedilol was the BB of choice if the patient had a BP >120 mm Hg or HR >80 bpm and angiotensin-converting enzyme inhibitor (ACEi) and ARB were switched to ARNi. A basic metabolic panel was ordered 1 week after every dose of adjustment of ACEi, ARB, or ARNi and 2 weeks after the initiation of SGLT2i. A variety of interventions were used to ensure patients were able to obtain medications.