82 Pharmacist-led heart failure medicines optimisation clincs in primary care – a service evaluation

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Introduction Initiation & optimisation of disease-modifying medicines in patients with heart failure with a reduced ejection fraction (HFrEF) is the cornerstone of management(1). Delivering optimal medical therapy (OMT)* has proven morbidity & mortality benefits(1). The rising prevalence of heart failure (HF) & backlog pressure due the impact of COVID have put enormous pressure on the majority of heart failure services in the country. There is a need to build capacity within HF services to meet demands. With appropriate training & support, GP practice based, clinical pharmacists could deliver HF medicines optimisation clinics in the community. This would aim to complement existing specialist services, strengthen capacity & improve patient access to medicines with significant prognostic value. In a pilot project, we aim to determine the efficacy & safety to conduct community based, pharmacist-led clinics to optimise pharmacotherapy for patients with chronic heart failure. Method Pharmacist prescribers working in participating GP surgeries completed a variety of HF training. A HF competency framework was utilised, evidence of learning & skills was documented. Patients with HFrEF were identified by the local hospital HF team after new diagnosis or decompensation. Patients were also identified after auditing existing primary care HF registers, prioritising patients who had not yet achieved OMT. Pharmacists delivered consultations; performed clinical examination, prescribed medication, reviewed blood results & arranged follow-up. Patient education was provided together with HF self-management plans. Pharmacists had access to multi-disciplinary team meetings & HF consultant advice throughout. All appointments were recorded together with details of symptom burden, drug interventions and adverse events (ADRs). Where clinical advice from the HF consultant was sought, this was recorded. Patients continued under pharmacist follow-up until they were taking OMT, after which a repeat echocardiogram & BNP serology was arranged. Patient questionnaires were provided. Results 59 patients were seen in pharmacist-led clinics (Table 1). A total of 170 pharmacist appointments yielded 93 new drug initiations (Picture 1) & 71 dose titrations. After pharmacist-led medicines optimisation, HF symptoms reduced by half a point on the NYHA scale (1.81 to 1.34, N=59), NT-pro-BNP reduced from 5265pg/L to 1265pg/L (N=21), LVEF increased from 37% to 42% (N=18) for the average patient (Table 2). There were 29 ADRs reported. The most common were hyperkalaemia (N=11), renal function decline (N= 5) and hypotension (N=4). All of the ADRs were safely managed in primary care. Pharmacists were largely working autonomously; only 18% (30/170) of consultations required specialist advice & 6 patients were referred back to the hospital team, due to complexity. Overwhelmingly patients felt the service was effective. Patients had confidence in the pharmacist & the majority would recommend the same type of appointment to another person who had a similar condition (Picture 2). Conclusion Heart failure medicines optimisation can be delivered safely, efficiently & competently in primary care, by suitably trained pharmacist prescribers. Further service evaluation & expansion is urgently needed to improve access to heart failure care in primary care. References McDonagh, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42:3599-3726. doi:10.1093/eurheartj/ehab368. Footnote: * OMT is defined as maximal tolerated doses of ‘quadruple therapy’; beta-blockers; mineralocorticoid receptor antagonists (MRA); angiotensin receptor neprilysin inhibitors (ARNi); and sodium-glucose cotransporter-2 inhibit Conflict of Interest Astra-Zeneca funded the 12 month pilot

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