A proactive care pathway that improves medical therapy for patients with heart failure with reduced ejection fraction and implantable cardiac devices
Authors: Williams H J , Diab I , Nightingale A K 
Published: November 2023

Abstract

Background
The UK model for follow-up of most patients with implantable cardiac devices is in a device clinic led by cardiac physiologists. This may be their only contact with cardiac services for several years. Many of these patients have heart failure with reduced ejection fraction (HFrEF) but do not have ongoing review in a heart failure clinic if they are clinically stable.
ESC guidelines recommend four drug classes for all patients with HFrEF; implementing pathways that increase the prescription of these drugs is a priority as it improves quality of life, reduces hospitalisation and increases lifespan.
A new clinical pathway was therefore created to achieve this in patients with cardiac devices at a tertiary cardiac centre in the UK, by combining device and heart failure follow-up in a single clinic.

Purpose
To evaluate the effectiveness of a new clinical pathway to improve the delivery of medical heart failure therapy to patients with cardiac devices and HFrEF.

Methods
Education on HFrEF diagnosis was delivered to the cardiac physiology team. This team then screened patients attending device follow-up clinics to identify those with HFrEF, through review of medical records and cardiac imaging. All patients with HFrEF identified by screening, who were not already under the active care of a heart failure team, were referred by the physiology team to a new combined heart failure device clinic.

Results
From Aug 2022 to Jan 2023, 107 patients were referred to the new heart failure device clinic. 102/107 (95%) patients attended. 72/102 (71%) had HFrEF, 19/102 (19%) had HFmrEF and 16/102 (16%) had HFpEF.
Of the 72 patients with HFrEF, mean age was 70 years (range 29 – 90) and 79% were male. At baseline, 4/72 (6%) were in NYHA class I, 41/72 (57%) class II, 27/72 (38%) class III and 0/72 in class IV.
At baseline, only 15/72 (21%) patients with HFrEF were prescribed all four drug classes. Following heart failure device clinic review, after an average of 1.9 appointments, 44/72 (61%) patients were prescribed these four drug classes (see Figure 1).
Doses of drug classes prescribed at baseline were increased in 18/72 (25%) patients and 6/37 (16%) patients who were taking ACE-I or ARB at baseline were switched to ARNI.
Iron status was assessed in 52 patients. 20/52 (38%) were iron deficient and managed with IV iron.

Conclusions
Many patients with HFrEF and cardiac devices are neither treated with the four key drug classes nor under active follow up by a heart failure team. Proactive screening of patients attending the device clinic by the cardiac physiology team identified patients with HFrEF who were not optimally treated. Subsequent review in a combined heart failure device clinic led to an increase from 21% to 61% of patients taking all four guideline-recommended drugs.
Proactive multi-disciplinary working is an effective strategy to improve medical therapy and therefore prognosis for patients with HFrEF and cardiac devices.