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- Title
2016 - Review: In HF with reduced EF, nurse-led titration of HF drugs reduces hospitalizations and mortality.
- Authors
Shah, Tina; Deswal, Anita
- Abstract
Question In patients with heart failure (HF) and reduced ejection fraction, does nurse-led titration (NLT) of angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), and β-adrenergic blockers reduce hospitalizations and mortality compared with usual care? Review scope Included studies compared titration of ACE inhibitors, ARBs, and β-adrenergic blockers by HF nurse specialists or nurse practitioners in outpatient clinics or patients' homes with titration by primary care physicians (usual care) in patients ≥18 years of age. These patients had symptomatic HF and reduced ejection fraction and were prescribed ≥1 of the 3 drug classes. Outcomes were all-cause and HF hospitalization, all-cause mortality, all-cause event-free survival (based on all-cause hospitalization or mortality events), and adverse events. Review methods MEDLINE, EMBASE/Excerpta Medica, and Cochrane Central Register of Controlled Trials (Dec 2014); World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov (Jul 2015); reference lists; and gray literature were searched for randomized controlled trials (RCTs). 7 RCTs (n =1684, mean age 59 to 81 y, about 50% women in 4 RCTs and 79% in 1 RCT) met the inclusion criteria. 1 additional study published in abstract form met the inclusion criteria but was excluded because insufficient data were available. 2 RCTs titrated all 3 drug classes; 2 titrated ACE inhibitors and β-adrenergic blockers, and 3 titrated only β-adrenergic blockers. 1 RCT had adequate allocation concealment, 2 had adequate outcome data, and 4 blinded outcome assessors; no RCTs blinded patients or health care professionals. Follow-up ranged from 6 to 18 months (median 12 mo). Main results NLT reduced all-cause and HF hospitalizations, all-cause mortality, and a composite of hospitalization or all-cause mortality compared with usual care (Table). 2 RCTs provided adverse event data: 1 reported 1 adverse event in the NLT group, and 1 reported no adverse events in either group. Conclusion In patients with heart failure and reduced ejection fraction, nurse-led titration of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and β-adrenergic blockers reduces hospitalizations and all-cause mortality compared with usual care.
- Subjects
ADRENERGIC beta blockers; ACE inhibitors; CARDIOVASCULAR disease nursing; CONFIDENCE intervals; DOSE-effect relationship in pharmacology; HEART failure; HOSPITAL care; INFORMATION storage &; retrieval systems; MEDICAL databases; MEDICAL information storage &; retrieval systems; MEDLINE; MORTALITY; NURSE practitioners; GENERAL practitioners; PRIMARY health care; SURVIVAL analysis (Biometry); SYSTEMATIC reviews; EVIDENCE-based nursing; RANDOMIZED controlled trials; RELATIVE medical risk; TREATMENT effectiveness; ANGIOTENSIN receptors; DESCRIPTIVE statistics
- Publication
ACP Journal Club, 2016, Vol 164, Issue 8, p4
- ISSN
1056-8751
- Publication type
Article