{
  "abstract": "Introduction Heart failure (HF) is a significant cause of mortality, long-term disability and chronic poor health. It is the number one cause of hospitalisation in people over the age of 65. Failure to treat HF correctly can result in increased morbidity and mortality. Royal Berkshire Hospital (RBH) Trust and NICE guidelines facilitate initiation and titration of the 4 most effective heart failure with reduced ejection fraction (HFrEF) drugs to the target dose in symptomatic HFrEF patients as quickly and as safely as possible. All 4 drug classes have a Class I A recommendation in HFrEF, are equally weighted and additive; therefore, ideally, all 4 drugs should be initiated to avoid the risk of drugs never being prescribed. Parallel titration every 2-4 weeks reduces the number of HF clinic visits to optimal dosing. All patients with heart failure are at risk of hypotension, renal impairment and hyperkalaemia. Drug sequencing order is tailored according to the patient’s blood pressure, heart rate, fluid status and renal function. Sick day rules are particularly relevant to a hospitalised population; when patients are unwell, then medications may all be temporarily suspended. It is, however, important to restart these medications as soon as possible, for prognostic benefit.Aim This project sought to establish whether there were robust reasons for not prescribing HFrEF medication to an elderly, hospitalised population with HFrEF, and whether this was clearly documented. When these medications are not used or held, or stopped, it is essential to clearly document the clinical reasoning to ensure patient safety and uphold the standard of care. This supports continuity of care. Having a documented reason for omitted medications prevents inappropriate re-initiation of that medication. This includes specifying the clinical contraindication (e.g., hypotension, renal dysfunction, bradycardia) and noting any patient preferences. This project also highlights whether device therapy has been considered where appropriate.Standards/Criteria Royal Berkshire NHS Foundation Trust Guidelines take into account national guidance based on primary evidence, including National Institute for Health and Care Excellence (NICE) and European Society of Cardiology (ESC) guidelines. It facilitates initiation and titration of the 4 most effective HFrEF drugs to the target dose in symptomatic HFrEF patients as quickly and as safely as possible. For people who have heart failure with reduced ejection fraction and chronic kidney disease with an eGFR below 30 ml/min/1.73 m2, the specialist heart failure MDT should consider liaising with a renal physician.Methodology Four-months of retrospective study of patients aged 75 or above diagnosed with Heart Failure with reduced ejection fraction referred to heart failure specialists in four months from 1st of June to 30th of September 2024. Electronic clinical letters were reviewed, and data were collected.Results 52 patients were referred to HF specialists from 1st of June to 30th of September 2024, among which, 16 were females, and 36 were males. 17, 33 and 2 were in the age group of 75-80, 81-90 and >90, respectively. Among 52 patients, 47 were seen by heart failure specialists, and 5 did not receive a specialist consultation. 69% were either on ACE I, ARBs or ARNI. In 11%, it was not clearly documented why this class of medication was stopped or held. In the remaining 20%, there was a rationale for not giving medication in view of either hypotension, AKI or dizziness. 45 (86.5%) were on BBlocker, and 7 were without, where only 4 patients had reasons specified for not continuing BBlocker, i.e. bradycardia or poor tolerance. There was no documentation for the remaining 3 patients. 59% patients received MRA without having any side effects. 41% could not tolerate, but reasons for not having MRA were mentioned in only 19% i.e hypotension, deranged renal profile or LV function improved post-ablation. 81% have not had clear documentation. 78.8% were started on SGL2 Inhibitors without having complications. 21% were deprived of this class of drug, where no reasons were mentioned for 81.8% of these. 65% were diuresed to euvolemia, while 35% were either having ongoing uptitration or couldn’t tolerate it. Among 52 patients, 21% patients underwent device implantation to optimise LV function in addition to medical management. 53.8% did not need device therapy. 9.6% indicated device therapy but had no related documentation. 9.6% passed away before discussing device therapy.Conclusion The data illustrate a notable difference in prescribing, with older people being less likely to receive guideline-directed HFrEF medication. Significant gaps were identified in the documentation of reasons for medication omission or discontinuation. Most patients were successfully diuresed to euvolaemia, and a notable portion underwent device implantation after medical therapy optimisation.Reference Table 1: https://www.nice.org.uk/guidance/ta314/chapter/1-RecommendationsAbstract 116 Figure 1Abstract 116 Table 1Treatment options with ICD or CRT for people with heart failure who have left ventricular dysfunction with an LVEF of 35% or less (according to NYHA class, QRS duration and presence of LBBB)(Nice Guidance, 2014, point 1.2, Table 1)",
  "authors": [
    {
      "affiliations": [
        "Royal Berkshire Hospital, Reading, United Kingdom"
      ],
      "name": "Muhammad Zohaib Amjad"
    },
    {
      "affiliations": [
        "Royal Berkshire Hospital, Reading, United Kingdom"
      ],
      "name": "Wajeeha Latif"
    },
    {
      "affiliations": [
        "Royal Berkshire Hospital, Reading, United Kingdom"
      ],
      "name": "Humda Zafar"
    },
    {
      "affiliations": [
        "Royal Berkshire Hospital, Reading, United Kingdom"
      ],
      "name": "Lindsey Tilling"
    }
  ],
  "title": "116 Pharmacological and device therapy of heart failure with reduced ejection fraction in elderly patients and proper documentation of rationale for not giving core foundational HFrEF therapies",
  "uid": "1e80fbc0-51bb-57d7-b411-b8151acf114d"
}