2025 Southeastern Residency Conference

Title: Pharmacist Impact on Inpatient Guideline-Directed Medical Therapy Prescribing in Heart Failure with Reduced Ejection Fraction


Authors: Hayley Harrod-Meeks, Kyle Starling, Hunter McDowell 


Objective: This project aimed to evaluate the impact of pharmacist intervention on inpatient prescribing of HFrEF GDMT at Atrium Health Navicent (AHN).


Self Assessment Question: True or False: Pharmacist intervention can increase inpatient prescribing of HFrEF GDMT?


Background: Heart failure with reduced ejection fraction (HFrEF) is a serious condition associated with high morbidity and mortality. The American Heart Association (AHA) guidelines recommend four classes of medications to reduce these risks: renin-angiotensin-aldosterone system (RAAS) inhibitors, beta blockers, mineralocorticoid receptor antagonists (MRAs), and sodium-glucose co-transporter 2 (SGLT-2) inhibitors. However, hesitancy to initiate or adjust these medications during hospitalization due to transient hypotension or acute kidney injury may worsen patient outcomes. We hypothesize that pharmacists play a key role in improving inpatient guideline-directed medical therapy (GDMT) prescribing. 


Methods: This was a pre-post study that involved physician education and pharmacist intervention. Prior to the intervention period, a brief educational guide on HFrEF GDMT was provided to hospital physicians. During the intervention period, patient chart reviews were conducted to make appropriate recommendations to physicians and to determine outcomes. Patients were included in the analysis if they met all four of the following criteria: were 18 years-old or older, admitted to AHN, had an ejection fraction less than 40%, and had an EPIC-calculated readmission risk score of at least 20%. Key exclusion criteria included patients requiring renal replacement therapy at discharge or those who died during hospital admission. The primary outcome was the percentage of patients discharged on each eligible pillar of GDMT. Secondary outcomes included the percentage of patients discharged on each individual GDMT pillar and the percentage of patients readmitted to AHN within 30 days of discharge. Chi-square analysis was performed to assess differences in outcomes. 


Results: In the intervention group, 24% of patients met the primary outcome while only 12% of baseline patients were discharged on all eligible GDMT pillars of HFrEF (P=0.023). Out of each medication class, the MRAs and SGLT-2 inhibitors were the least commonly prescribed in both groups. However, prescribing of both MRAs and SGLT-2 inhibitors was statistically higher in the intervention group, with a 16.3% increase in MRA prescribing (P=0.014) and a 14.6% increase in SGLT-2 inhibitor prescribing (P=0.031). Thirty-day readmission rates were reduced by 7.7% in the intervention group, though this was not statistically significant (P=0.244). 


Conclusion: In this pre-post study, we found that pharmacist intervention can significantly increase inpatient HFrEF GDMT prescribing, especially by increasing the prescribing of MRAs and SGLT-2 inhibitors. 30-day readmission rates also trended down in the intervention group, though not significantly. Key limitations in this study included physician turnover and hesitancy to change HFrEF regimens when an acute heart failure exacerbation was not the patient’s primary problem. Overall, this study showed that pharmacists play a key role in helping improve inpatient HFreF GDMT prescribing.