“Bridging Guidelines and Real World Barriers: Reflections on GDMT Optimization in Heart Failure”

IF 2.3 3区 医学 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS
Ibadullah Tahir, Hunain Shahbaz, Aimal Khattak
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Patients who discontinued the program (perhaps due to severe intolerance) were excluded; thus the true burden of AEs may be underestimated. Only four AE domains were assessed, omitting others (e.g., volume depletion, gastrointestinal symptoms, or device-related issues) that can also limit GDMT. Finally, standardized definitions of “titration limiting” AEs were not detailed. As the authors note, establishing uniform AE criteria is essential for comparing programs and guiding practice [<span>1</span>].</p><p>Importantly, Velasco's results should be interpreted alongside broader barriers to GDMT uptake. Systematic reviews and registry data have documented multifactorial obstacles including clinician inertia, patient comorbidities, socioeconomic factors, and health system challenges that suppress GDMT use [<span>2, 5</span>]. The 2022 AHA/ACC/HFSA guideline reiterates that quadruple GDMT markedly improves survival and symptoms, yet emphasizes tailoring therapy to individual patient risk/benefit profiles [<span>3</span>]. Similarly, recent ACC consensus guidance highlights “special cohorts” (older adults, frailty, coexisting organ dysfunction, and socioeconomic barriers) that necessitate flexible GDMT strategies [<span>6</span>]. In this light, Velasco's finding that obesity was associated with higher titration success may reflect survivor bias or phenotype differences, and warrants further study.</p><p>Where Velasco et al. add value is by quantifying how often AEs intrude on a dedicated titration effort. Their high AE rate parallels other quality improvement experiences: for example, a nurse/pharmacist led titration program achieved target GDMT in 80% of patients by 6 months [<span>6</span>] but only after intensive follow-up and patient education. 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引用次数: 0

Abstract

Velasco et al. address a critical issue in contemporary HF care by examining titration limiting adverse effects (AEs) in a specialized guideline directed medical therapy (GDMT) optimization program [1]. In their single center cohort (n = 254 completers), 59% of patients encountered ≥ 1 AE (hypotension, bradycardia, hyperkalemia, renal dysfunction) hindering GDMT titration [1]. Notably, younger, nonischemic patients more often reached target doses. These observations underscore the reality that, despite guidelines advocating quadruple therapy (ARNi/ACEi/ARB, beta-blockers, MRA, SGLT2i) for HFrEF [2] real world implementation lags: fewer than one in five eligible patients currently receive all four classes [5].

Velasco et al. are to be commended for quantifying AE rates within an intensive titration program and for analyzing predictors of submaximal dosing (e.g., older age and atrial fibrillation predicted lower beta blocker titration) [1]. This granular approach highlights important heterogeneity: for example, patients without hypertension or with atrial fibrillation had more difficulty up titrating renin angiotensin blockers [1]. Such findings point to the need for personalized strategies. However, the study's retrospective, single center design and focus on program completers may limit generalizability. Patients who discontinued the program (perhaps due to severe intolerance) were excluded; thus the true burden of AEs may be underestimated. Only four AE domains were assessed, omitting others (e.g., volume depletion, gastrointestinal symptoms, or device-related issues) that can also limit GDMT. Finally, standardized definitions of “titration limiting” AEs were not detailed. As the authors note, establishing uniform AE criteria is essential for comparing programs and guiding practice [1].

Importantly, Velasco's results should be interpreted alongside broader barriers to GDMT uptake. Systematic reviews and registry data have documented multifactorial obstacles including clinician inertia, patient comorbidities, socioeconomic factors, and health system challenges that suppress GDMT use [2, 5]. The 2022 AHA/ACC/HFSA guideline reiterates that quadruple GDMT markedly improves survival and symptoms, yet emphasizes tailoring therapy to individual patient risk/benefit profiles [3]. Similarly, recent ACC consensus guidance highlights “special cohorts” (older adults, frailty, coexisting organ dysfunction, and socioeconomic barriers) that necessitate flexible GDMT strategies [6]. In this light, Velasco's finding that obesity was associated with higher titration success may reflect survivor bias or phenotype differences, and warrants further study.

Where Velasco et al. add value is by quantifying how often AEs intrude on a dedicated titration effort. Their high AE rate parallels other quality improvement experiences: for example, a nurse/pharmacist led titration program achieved target GDMT in 80% of patients by 6 months [6] but only after intensive follow-up and patient education. Likewise, a recent pilot trial of a remote monitoring titration clinic showed significant improvements in GDMT “score” versus usual care [4] suggesting that innovative care models can partially overcome barriers. Integrating such multidisciplinary or telehealth approaches could mitigate some AEs by allowing more frequent monitoring and dose adjustments.

Should include prospective studies that (1) incorporate patient reported outcomes and quality of life metrics, (2) evaluate strategies to safely accelerate GDMT (as exemplified by the STRONG HF trial's outcomes), and (3) develop decision support tools to flag at-risk patients. Velasco et al. rightly call for consensus on defining GDMT related AEs [1]; in parallel, we need predictive models that identify who will benefit from slower versus faster titration. Importantly, addressing non AE barriers (medication access, adherence support, care coordination) will be equally critical. In summary, Velasco et al. provide valuable real world data on the complexity of GDMT optimization [1]. Their findings remind us that human factors from physiology to behavior shape GDMT implementation. By acknowledging these nuances while continuing to pursue intensive titration, the HF community can advance toward truly patient centered care.

All authors have read and approved the final version of manuscript.

The authors have nothing to report.

The authors have nothing to report.

The authors declare no conflicts of interest.

弥合指南和现实世界的障碍:对心力衰竭GDMT优化的思考
Velasco等人通过在专门指导药物治疗(GDMT)优化程序[1]中检查滴定限制不良反应(ae),解决了当代心衰护理中的一个关键问题。在他们的单中心队列中(n = 254名完成者),59%的患者出现≥1次AE(低血压、心动过缓、高钾血症、肾功能不全),阻碍GDMT滴定[1]。值得注意的是,年轻的非缺血性患者更容易达到目标剂量。这些观察结果强调了这样一个现实:尽管指南提倡对HFrEF[5]进行四联治疗(ARNi/ACEi/ARB、β受体阻滞剂、MRA、SGLT2i),但现实世界的实施滞后:目前只有不到五分之一的符合条件的患者接受了所有四类[5]。Velasco等人量化了强化滴定方案中的AE率,并分析了亚最大剂量的预测因子(例如,老年人和房颤预测较低的阻滞剂滴定)[1]。这种颗粒状方法突出了重要的异质性:例如,没有高血压或房颤的患者在滴定肾素血管紧张素阻滞剂[1]时更困难。这些发现表明了个性化策略的必要性。然而,该研究的回顾性、单中心设计和对项目完成者的关注可能限制了通用性。停止治疗的患者(可能是由于严重的不耐受)被排除在外;因此,ae的真正负担可能被低估了。仅评估了四个AE域,忽略了其他可能限制GDMT的域(例如,体积损耗、胃肠道症状或设备相关问题)。最后,“滴定极限”ae的标准化定义没有详细说明。正如作者所指出的那样,建立统一的AE标准对于比较方案和指导实践是至关重要的。重要的是,Velasco的结果应该与GDMT吸收的更广泛障碍一起解释。系统回顾和登记数据记录了多因素障碍,包括临床医生惰性、患者合并症、社会经济因素和卫生系统挑战,这些因素抑制了GDMT的使用[2,5]。2022年AHA/ACC/HFSA指南重申,四倍GDMT可显著改善生存和症状,但强调根据患者个体风险/获益情况量身定制治疗方案[10]。同样,最近的ACC共识指南强调了“特殊人群”(老年人、体弱者、共存的器官功能障碍和社会经济障碍)需要灵活的GDMT策略[10]。鉴于此,Velasco的发现肥胖与较高的滴定成功率相关,可能反映了幸存者偏见或表型差异,值得进一步研究。Velasco等人增加价值的地方是通过量化AEs侵入专用滴定工作的频率。他们的高不良反应发生率与其他质量改进经验相似:例如,护士/药剂师领导的滴定计划在6个月前达到了80%的患者GDMT目标,但这是在强化随访和患者教育之后。同样,最近在远程监测滴定诊所进行的一项试点试验显示,与常规护理相比,GDMT“评分”有了显著改善,这表明创新的护理模式可以部分克服障碍。综合这种多学科或远程保健方法可以通过更频繁地监测和调整剂量来减轻一些不良反应。应该包括前瞻性研究:(1)纳入患者报告的结果和生活质量指标,(2)评估安全加速GDMT的策略(如STRONG HF试验的结果),以及(3)开发决策支持工具来标记高危患者。Velasco等人正确地呼吁就GDMT相关ae的定义达成共识[10];同时,我们需要预测模型来确定谁将从较慢的滴定和较快的滴定中受益。重要的是,解决非AE障碍(药物获取、依从性支持、护理协调)也同样至关重要。总之,Velasco等人提供了关于GDMT优化复杂性的有价值的真实世界数据[1]。他们的发现提醒我们,从生理到行为的人为因素塑造了GDMT的实施。通过认识到这些细微差别,同时继续追求强化滴定,心衰社区可以向真正以患者为中心的护理迈进。所有作者都已阅读并批准了稿件的最终版本。作者没有什么可报告的。作者没有什么可报告的。作者声明无利益冲突。
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来源期刊
Clinical Cardiology
Clinical Cardiology 医学-心血管系统
CiteScore
5.10
自引率
3.70%
发文量
189
审稿时长
4-8 weeks
期刊介绍: Clinical Cardiology provides a fully Gold Open Access forum for the publication of original clinical research, as well as brief reviews of diagnostic and therapeutic issues in cardiovascular medicine and cardiovascular surgery. The journal includes Clinical Investigations, Reviews, free standing editorials and commentaries, and bonus online-only content. The journal also publishes supplements, Expert Panel Discussions, sponsored clinical Reviews, Trial Designs, and Quality and Outcomes.
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