Holistic approach to drug therapy in a patient with heart failure.

Heart failure (HF) is a growing global public health problem affecting at least 26 million people worldwide. The evidence-based landscape for HF treatment has changed at a rapid rate over the last 30 years. International guidelines for the management of HF now recommend the use of four pillars in all patients with reduced ejection fraction: angiotensin receptor neprilysin inhibitors or ACE inhibitors, beta blockers, mineralocorticoid receptor antagonists and sodium-glucose co-transporter-2 inhibitors. Beyond the main four pillar therapies, numerous further pharmacological treatments are also available in specific patient subtypes. These armouries of drug therapy are impressive, but where does this leave us with individualised and patient-centred care? This paper reviews the common considerations needed to provide a holistic, tailored and individual approach to drug therapy in a patient with HF with reduced ejection fraction, including shared decision making, initiating and sequencing of HF pharmacotherapy, drug-related considerations, polypharmacy and adherence.

Polypharmacy definition and prevalence in heart failure: a systematic review.

Polypharmacy and heart failure are becoming increasingly common due to an ageing population and the rise of multimorbidity. Treating heart failure necessitates prescribing of multiple medications, in-line with national and international guidelines predisposing patients to polypharmacy. This review aims to identify how polypharmacy has been defined among heart failure patients in the literature, whether a standard definition in relation to heart failure could be identified and to describe the prevalence. The Healthcare Database Advanced Search (HDAS) was used to search EMBASE, MEDLINE, PubMed, Cinahl and PsychInfo from inception until March 2021. Articles were included of any design, in patients ≥ 18 years old, with a diagnosis of heart failure; that explicitly define and measure polypharmacy. Data were thereafter extracted and described using a narrative synthesis approach. A total of 7522 articles were identified with 22 meeting the inclusion criteria. No standard definition of polypharmacy was identified. The most common definition was that of " ≥ 5 medications." Polypharmacy prevalence was high in heart failure populations, ranging from 17.2 to 99%. Missing or heterogeneous methods for defining heart failure and poor patient cohort characterisation limited the impact of most studies. Polypharmacy, most commonly defined as ≥ 5 medications, is highly prevalent in the heart failure population. There is a need for an internationally agreed definition of polypharmacy, allowing accurate review of polypharmacy issues. Whether an arbitrary numerical cut-off is a suitable definition, rather than medication appropriateness, remains unclear. Further studies are necessary to understand the relationship between polypharmacy with specific types of heart failure and related comorbidities.

A competency framework for clinical pharmacists and heart failure.

OBJECTIVES: Heart failure is an escalating 'pandemic' with malignant outcomes. Clinical pharmacist heart failure services have been developing for the past two decades. However, little clarity is available on the additional advanced knowledge, skills and experience needed for pharmacists to practice safely and competently. We aimed to provide an expert consensus on the minimum competencies necessary for clinical pharmacists to deliver appropriate care to patients with heart failure. METHODS: There were four methodological parts; (1) establishing a project group from experts in the field; (2) review of the literature, including existing pharmacy competency frameworks in other specialities and previous heart failure curricula from other professions; (3) consensus building, including developing, reviewing and adapting the contents of the framework; and (4) write-up and dissemination to widen the impact of the project. KEY FINDINGS: The final framework defines minimum competencies relevant to heart failure for four different potential levels of specialism: all pharmacists regardless of role (Stage 1); all patient-facing clinical pharmacists (Stage 2); clinical pharmacists with specific planned roles in the care of heart failure patients (Stage 3); and regionally/nationally/internationally recognised expert pharmacists with a direct specialism in heart failure (Stage 4). CONCLUSIONS: The framework delivers the vital first step needed to help standardise care, give pharmacists a blueprint for career progression and continuing professional development and bring clarity to the role of the pharmacist. Future collaboration between professional bodies and training providers is needed to develop structured programmes to align with the framework and facilitate training and resultant accreditation.