Pharmacist-led optimization of heart failure medications: A systematic review

Medications are a cornerstone of treatment of heart failure (HF) with reduced ejection fraction, thus pharmacists are valuable members of the multidisciplinary team approach to long-term patient management. As pharmacists' scope of practice has expanded, growing evidence shows an evolution in pharmacists' roles in the care of patients with HF. To synthesize the literature describing implementation of pharmacist-led medication titration and clinical assessments on outcomes in ambulatory patients with HF. MEDLINE, Embase, and Cochrane Controlled Register of Trials were searched from 2007 to March 18, 2020. English language articles that evaluated implementation of pharmacist-led medication titration in ambulatory patients with HF. Studies with interventions that involved pharmacists prescribing to initiate, modify, or discontinue medications with independent authority or under a collaborative practice agreement were considered. Ten retrospective studies from 718 identified articles were included. All studies incorporated pharmacist-led guideline-directed medical therapy (GDMT) titration, two with independent pharmacist prescribing in a multidisciplinary HF clinic, and seven in a pharmacist-only clinic. Patients were referred from both inpatient and outpatient settings and had an average reported range of 1-5.7 visits with pharmacists. While four studies exclusively included patients with HF and ejection fraction below 45%, the mean ejection fraction of all included patients ranged from 20% to 42%. Four studies showed an increased proportion of patients on GDMT or target doses after pharmacist prescribing. Four out of six studies showed a significant decrease in all-cause hospitalizations and one of two studies reported a significant decrease in all-cause mortality rate with intervention. This study found that pharmacist-led medication optimization increased the use of GDMT in ambulatory patients with HF, and may be associated with fewer hospitalizations and deaths. Future randomized controlled trials should evaluate the impact of adding pharmacist-led HF medication optimization to standard of care on clinical outcomes.