I’m Dr Kevin Kam from Hong Kong, Prince of Wales Hospital.
What motivated you to implement a strategy to optimise guideline-directed medical therapy (GDMT) among patients with heart failure with reduced ejection fraction (HFrEF) at the Heart Failure Clinic?
I am actually working as a general cardiologist, and my special interest is actually in Echo first. I devoted myself pretty much in heart failure (HF) in the recent couple years or so, because I see that the preference of the HF population is growing in our localities.
I think the main challenges right now in Hong Kong is that kind of the population (HF population) are getting sicker and sicker. And then we have a lot of patients come in with HFrEF as well, and their outcome is really bad. The HF hospitalisation readmission rate could be up to around 20% in 3 months time, the mortality is actually very high. So I think that we need something better, such as the ambulatory HF clinics or ambulatory centre to follow-up these patients more closely and to introduce and uptitrate the GDMT in order to help these patients out.
Please describe the dose titration and GDMT optimisation strategy that was implemented at the Heart Failure Clinic.
Well, we tried to recruit the patients with post-discharge HF because they are a vulnerable group, as I have eluded. This group of population, they are prone to having HF rehospitalisation. So our approach is mainly like the simultaneous approaches. We try to introduce small dosage of the GDMT, for example the RAAS (renin-angiotensin-aldosterone system) blocker, beta blocker, and then the MRA (mineralocorticoid receptor antagonists), if the blood pressure allows, and then we will just go from there.
For some patients who actually are kind of hypotensive, we will adopt to use the beta blocker and the SGLT2 inhibitors first, and then followed by the RAAS blocker and the MRA. And if the patient is having HFrEF, for example the EF <40%, we try to use the ARNi (angiotensin receptor-neprilysin inhibitor), which is sacubitril / valsartan, as the first RAAS blocker to use, because it’s actually evidence-based to reduce cardiovascular mortality, as well as reduce subsequent HF rehospitalisations. So with that, we are able to uptitrate the RAAS blockade for >50% of the full dosage, and beta blocker, I think is up to around 70% we achieved maximum dosage, and for MRA it’s around 70% as well.
What key outcomes were observed after implementing the Heart Failure Clinic workflow at Prince of Wales Hospital?
I think we have tried to adopt [an approach] very similar to that of the STRONG-HF approach. We tried to introduce and uptitrate that kind of GDMT in a rapid manner. Before discharge we tried to add on at least 3 GDMT, at least at a lower dosage. After that we will recruit the patients to our ambulatory HF centre so that we can have the uptitration and even introduction of further GDMT. So we have actually recruited into our Reduced HF Registry [study], which is a prospective registry trying to compare our data with the historical cohort to see the primary endpoints of the all-cause mortality, as well as HF hospitalisation.
So here shows the results, the mean age was around 67, 70% of them were female, 60% of them were in the HFrEF cohort, and the mean EF was 39%. 28% of them were having ischemic cardiomyopathies. So with the really diligent titration of the GDMT, we could achieve the RAAS blocker, including ARNi, up to 91%, beta blocker 90%, MRA 72%, SGLT2 inhibitors 96%.
With that, we actually had much improvement in all-cause mortality, reduced by 78% compared with the historical cohort, and with much less HF hospitalisation; 34% reduction compared to that of the historical cohort, achieved around 8.6% in 3 months time. We were able to achieve improvement in the mean EF by 5% and increase in the KCCQ score by 63%, and also the patients can walk further by 34m in 6min walk distance. The NT-proBNP, which is a very important prognostic marker, showed a 45% reduction as compared to the historical cohort.
So this study actually has given us really good data, proving that the STRONG-HF approach could be done in Hong Kong, and also it is not just improving the patients’ quality of life, but also can make the patients liver longer, and also reduce the cost by having less HF rehospitalisations.
What were the challenges during this pilot strategy of optimising GDMT dose for your patients attending the heart failure clinic? How did you overcome them?
Speaking of challenges, I think that in Hong Kong, sometimes the patients might have a hard time coming back so frequently, especially if they have work to be done. And also for elderly we have to arrange transportation for them. And some of them may have inadequate social support. That makes it really difficult to uptitrate the GDMT for them, and also schedule frequent blood tests.
Another challenge is actually the funding and the resources implications. Although our data is actually similar to that of the STRONG-HF study, has proven to reduce the all-cause mortality as well as the HF rehospitalisation, but doing that is a huge investment to our healthcare system because we need to schedule very frequent follow-ups and we need to recruit the patients in the in-patient setting and that would be one of the challenge as well.
And other challenges is that right now because we are actually under Department of Medicine, we need to sort of be recognised as a regular service in our ambulatory day care centres. We need to talk to the stakeholders about the importance of these new services, how we could actually save costs and that is more work to be done.
Based on your study findings, what are the top 3 recommendations you have for other APAC clinicians who are looking to implement GDMT optimisation strategies in their institutions?
This is a very good question. I think that the most important thing is to have the ambulatory HF centre or clinic yourself, and then start to recruit the appropriate patients, so no matter the patients with HFrEF, HFmEF, or HFpEF, they will benefit from the GDMT. So from our experience is that if we recruited the right patients, they could improve their outcomes because they are going to readmit less compared with the standard care groups.
And I think that the most important is for the clinicians to see the patients more frequently, the best should be1 to 2 weeks time after the discharge and to introduce and to uptitrate the GDMT frequently and to make the patients feel that they are part of the team, and to reassure the patients that this kind of GDMT is going to improve their heart condition. That would give the patient the peace of mind so that they could keep their compliance and to achieve better symptom control.
And the third recommendation is that we have to set a common goal with the patients. Because we are working with the patient as a team, we have to understand what [are] their beliefs, and then what they want to achieve. For some of the patients, [they] would like to have improvement of symptoms, some of them would prefer to live longer. So we need to set a common goal, so as to understand what they actually want to achieve in 1 year’s time, or might be 2 years later. With that we could achieve a better adherence to the GDMT, and then they would be more committed to their lifestyle modification. This is one way to ensure the success of your program.
