The Increasing Complexity of Guideline-Directed Medical Therapy for Heart Failure with Reduced Ejection Fraction and Challenges for Real-world Implementation

The latest guidelines for heart failure with reduced ejection fraction (HFrEF) recommend concurrent treatment with four drug classes to improve patient outcomes. While physicians likely have the skillsets needed to navigate the complexities of multiple drug interactions, HF nurse prescribers lack experience needed to implement the latest guideline-directed medical therapy (GDMT). As nurse-led HF services continue to expand, implementing GDMT is essential for gold-standard care. We describe and compare the abilities of physician-led and nurse-led HF clinics in implementing GDMT in HFrEF within the outpatient setting. A retrospective multi-centre cohort study was performed on the pharmacotherapy patterns of HFrEF patients attending either a physician-led or nurse-led HF clinic in 2021. Pharmacotherapy patterns of prescribing on the pillars of HFrEF therapy were collected: ACEi/ARB/ARNi, BB, MRA, SGLT2i. 164 and 231 HFrEF patients were reviewed in a physician-led and nurse-led group respectively. Compared to physicians, there were significantly lower rates of MRA (42.0% vs 62.8%, P < 0.001) and SGLT2i (7.8% vs 24.4%, P < 0.001) prescribed by nurses. Most patients seen by physicians were treated with three drug classes (45.7%) versus two drug classes (50.2%) when seen by nurses. Ongoing gaps in GDMT implementation are driven by the suboptimal MRA and SGLT2i use. Patients seen by nurses were treated with less drug classes and less likely to be treated with MRA and SGLT2i compared to physicians. These findings highlight the ongoing difficulties autonomous nurse prescribers face in HF prescribing and the need for further educational supports.