CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 1, January – April 2024 AFRICA 13 therapy guidelines by highlighting the role of themultidisciplinary team (include physician, nurse and pharmacist) in the HF programme in improving left ventricular ejection fraction (EF) and reducing the rate of rehospitalisation. Methods This retrospective, observational study was performed to evaluate the adherence to guideline-directed medical therapy (GDMT) before (1 January to 31 December 2014) and after (1 January to 31 December 2015) the establishment of the HF programme among HF patients. The study was conducted at the Cardiac Centre, King Khalid Hospital in Riyadh, Saudi Arabia. Study approval was obtained from the ethics review committee of the Cardiac Centre. The Institute has developed guidelines for HF treatment regimens, including the use of ACEI/ARB and BB, as well as influenza and pneumococcal immunisation. The study participants included all chronic HF patients admitted to a single cardiac centre with EF less than 55%. Newly diagnosed acute HF cases (characterised by new or worsening symptoms and indications of HF, the leading cause of unexpected hospitalisation among patients) were excluded. A total of 400 patients were selected for this study, however, after applying the inclusion and exclusion criteria, eight people declined to participate, leaving 392 persons with chronic HF eligible for the research. The HF programme commenced in January 2015. Data collected were compared between the commencement of the programme (one-year time period) and that prior to the programme’s initiation (one-year time period). The study assessed the following: the rate of adherence to GDMT among chronic HF patients; the impact of the adherence to guideline recommendations on the HF programme and guideline-driven toolkit; and the impact of the multidisciplinary approach in the HF programme. The patients with HF were handled in accordance with the European Society of Cardiology (ESC) recommendations. According to the 2016 ESC recommendation, when patients are diagnosed with HF and have an EF of 35%, they should be started on ACEI/ARB and BB. When the patient is in sinus rhythm and the QRS length is less than 130 ms, cardiac resynchronisation therapy should be regarded as the therapy of choice. However, if the patient has refractory symptoms, digoxin, hydralazine and isosorbide dinitrate (H-ISDN), a left ventricular assist device (LVAD), or a heart transplant should be explored. When the patient is in sinus rhythm with a heart rate of more than 70 beats per minute, ivabradine should be started. Each HF patient was assessed for the use of GDMT based on these guidelines. The programme was assessed for the study outcomes, including the administration of BB, ACEI or ARB, pneumococcal immunisation, the influenza before- and after-programme, and hospital re-admission rate within 30 days of discharge. The three members of the programme were present together in the patient encounter, playing their respective roles. The physician’s role, being the leader of the team, was to conduct an initial evaluation, take a history, carry out a physical examination and investigation, and review the management plan. The clinical pharmacists and nurses evaluated and assessed the appropriate GDMTs according to evidence, ensuring compliance with prescriptions during hospitalisation and follow up, and delivery of adequate patient education regarding medication use. Patient data pertinent to the research were retrieved from the electronic medical record at two time periods after the initial visit, namely the first and 12th months. The collected data of EF and re-hospitalisation were then compared between the study groups to determine GDMT adherence. Statistical analysis SAS version 9.2 (SAS Institute, Inc, Cary, NC) was used to conduct the statistical analysis to observe the differences before and after the programme. The chi-squared test was used to observe the difference between two categorical variables and the dependent t-test was applied to observe the mean difference before and after the initiation of the programme. A p-value < 0.05 was considered statistically significant. Results The mean ± standard deviation age of the patients in 2014 was 59.82 ± 14.63 years with a male preponderance (78.95%), while the age was 58.02 ± 16.00 years with 73.49% males in 2015. Co-morbidities included obesity, diabetes mellitus, hypertension, atrial fibrillation, stroke, hypothyroidism, anaemia, chronic obstructive pulmonary disease, coronary artery disease (CAD) and dyslipidaemia. There was a significant difference in the number of patients with hypertension, CAD, dyslipidaemia and in New York Heart Association (NYHA) class III between year 2014 and 2015 (Table 1). The number of patients discharged on ACEI/ARB and BB, and with immunisation as per the guidelines is shown in Fig. 1. The use of ACEI/ARB was 75.59% in 2014 at discharge and 81.17% in 2015 (p = 0.249). BB at release increased from 87.83% in 2014 to 94.53% in 2015 (p = 0.021). The flu vaccine was given to 48.24% of patients in 2014 and 75.13% of the patients in 2015 (p < 0.001). The pneumococcal vaccine was administered to 44.22% of patients in 2014 and 75.13% of patients in 2015 (p < 0.001) (Table 2). Table 3 shows significant improvement in short-term outcomes, namely the 30-day re-hospitalisation rate. Patients’ re-admission within 30 days in 2014 was 14.21%, which was significantly reduced to 4.25% in 2015 after commencement of the programme (p < 0.001). Clinical improvement was evident after implementation of the GDMT as there was a statistically significant improvement in EF from 30.21% in the first month to 39.56% by the end of the 12th month (p = 0.001) in patients managed in 2015, whereas there was no significant improvement in EF in patients managed in 2014 (32.21% in the first month and 34.61% in the 12th month, p = 0.40). Furthermore, there was a significant difference in the frequency of re-hospitalisation episodes at the end of one year (p < 0.001) between the two groups. Discussion This study aimed to assess the effect of a multidisciplinary HF programme in the form of improved patient care after including a clinical pharmacist and nurse specialist, which showed a reduction in hospital re-admission in the first 30 days, from 14.21
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