Specialist nurse supervised in-hospital titration to target dose ACE inhibitor--is it safe and feasible in a community heart failure population?

BACKGROUND: Recently published guidelines from the ESC and practical recommendations from an international group of experts support the up-titration of ACE inhibitors at 1- to 2-week intervals. Observance of these guidelines could contribute to the under-dosing of ACE inhibitors at discharge in patients admitted with heart failure. Specialist heart failure nurse supervision of ACE inhibitor titration during the in-hospital stay could be a safe and effective means of avoiding this problem.

OBJECTIVE: This observational study examines the feasibility of specialist heart failure nurse supervised rapid titration of ACE inhibition to at least target dose in sequential, class IV heart failure patients admitted to the cardiology service with left ventricular failure and not previously treated with an ACE inhibitor.

METHODS: Fifty-two patients (mean age 71.9+/-11.6 years) were initiated on perindopril and titrated to maximally tolerated dose during the in-hospital phase. Indices of renal function (creatinine, urea, potassium) and systolic blood pressure were observed at baseline and at discharge from hospital and at 3 months. Lengths of stay and titration intervals were recorded.

RESULTS: The mean length of stay was 10.3+/-7.7 days and 98% of patients achieved at least target dose of perindopril before discharge. The average time to titration to final dose was 5.5+/-4.2 days. Systolic blood pressure decreased significantly from 132+/-28 mmHg on admission to 117+/-18 mmHg on discharge. Mean baseline urea, creatinine and potassium did not change from admission to discharge (urea 8.4+/-2.5 to 9.2+/-3.9 mmol/l, P=0.15; creatinine 122.7+/-30.3 to 122.4+/-35.4 micromol/l, P=0.93; potassium 4.0+/-0.5 to 4.0+/-0.3 mEq/l, P=0.86). No significant changes were observed in these parameters at 12 weeks. There were no recorded incidences of symptomatic hypotension or progressive renal dysfunction even in patients (n=25) with evidence of chronic renal impairment (creatinine >120 micromol/l).

CONCLUSIONS: Specialist heart failure nurse supervised initiation and rapid in-hospital titration of ACE inhibitor to at least target dose is feasible and safe in a severe heart failure population admitted with class IV heart failure. Routine application of this approach may help avoid under-dosing of ACE inhibitors without increasing length of hospital stay, and may reduce outpatient visits to heart failure clinics for titration.