Review from JAMA Internal Medicine — Pharmacist Care of Patients With Heart Failure — A Systematic Review of Randomized Trials

DESPITE MANY advances in congestive heart failure (CHF) therapy, worsening of clinical status, often to the point of requiring hospitalization, remains a common occurrence.¹ It is estimated that there are 700 000 hospitalizations for CHF per year in the United States. In the Studies of Left Ventricular Dysfunction registry of 6273 consecutive patients with CHF,² 19% were hospitalized 1 or more times for CHF and 27% died or were hospitalized for CHF within 1 year. In 2 large CHF trials, the Studies of Left Ventricular Dysfunction Treatment Trial³ and the Digitalis Investigation Group Trial,⁴ 26% and 27%, respectively, of patients in the active treatment groups were hospitalized at least once during the 3 to 4 years of follow-up. Indeed, approximately two thirds of the economic burden of CHF is due to hospitalizations for worsening clinical status.⁵

IN CANADA and the United States, approximately 40% of all deaths are attributed to cardiovascular disease, and this is expected to continue to increase with the aging of society.^1,2 The modifiable risk factors for cardiovascular disease are well-known, and randomized trials have conclusively demonstrated the efficacy of lowering blood pressure, controlling blood glucose levels, and managing dyslipidemia in reducing mortality and morbidity from cardiovascular disease.³

Diabetes mellitus is a coronary artery disease equivalent: patients with diabetes without prior coronary events have the same risk for myocardial infarction and coronary artery disease–related mortality as nondiabetic patients with prior myocardial infarction.¹ The combination of diabetes and hypertension markedly increases the risk of premature cardiovascular disease.^2-4 Although hypertension is a stronger risk factor for macrovascular cardiovascular events in patients with diabetes than glucose control,⁵ control of blood pressure (BP) in patients with diabetes is often suboptimal, with less than 12% achieving the currently recommended target level of 130/80 mm Hg.⁶

Background—: Hypertension control rates remain suboptimal. Pharmacists’ scope of practice is evolving, and their position in the community may be ideal for improving hypertension care. We aimed to study the impact of pharmacist prescribing on blood pressure (BP) control in community-dwelling patients. Methods and Results—: We designed a patient-level, randomized, controlled trial, enrolling adults with above-target BP (as defined by Canadian guidelines) through c ommunity pharmacies, hospitals, or primary care teams in 23 communities in Alberta. Intervention group patients received an assessment of BP and cardiovascular risk, education on hypertension, prescribing of antihypertensive medications, laboratory monitoring, and monthly follow-up visits for 6 months (all by their pharmacist). Control group patients received a wallet card for BP recording, written hypertension information, and usual care from their pharmacist and physician. Primary outcome was the change in systolic BP at 6 months. A total of 248 patients (mean age, 64 years; 49% male) were enrolled. Baseline mean±SD systolic/diastolic BP was 150±14/84±11 mm Hg. The intervention group had a mean±SE reduction in systolic BP at 6 months of 18.3±1.2 compared with 11.8±1.9 mm Hg in the control group, an adjusted difference of 6.6±1.9 mm Hg ( P =0.0006). The adjusted odds of patients achieving BP targets was 2.32 (95% confidence interval, 1.17–4.15 in favor of the intervention). Conclusions—: Pharmacist prescribing for patients with hypertension resulted in a clinically important and statistically significant reduction in BP. Policy makers should consider an expanded role for pharmacists, including prescribing, to address the burden of hypertension. Clinical Trial Registration—: URL: http://www.clinicaltrials.gov . Unique identifier: NCT00878566.