OBJECTIVES:

The objective is to determine the number of appointments required to titrate patients diagnosed with heart failure with reduced ejection fraction (HFrEF), to the maximum tolerated dose (MTD) of angiotensin-converting enzyme inhibitor (ACEi), angiotensin-receptor blocker (ARB) and angiotensin receptor neprilysin inhibitor (ARNI) (sacubitril/valsartan) medications. Secondly, we aim to estimate the cost of outpatient appointments to titrate medicines.

METHODS:

A survey was developed and was sent via email by Novartis Ireland to the Irish Association of Heart Failure nurses. The survey was delivered via an online platform. HF nurses were asked how many outpatient appointments are required for HFrEF patients to reach MTD of the most commonly prescribed ACEi (enalapril, lisinopril, perindopril, and ramipril) and ARBs (candesartan, losartan, and valsartan) as well as ARNI. The cost of an outpatient appointment was obtained via email communication with the Healthcare Pricing Office.

RESULTS:

Thirty-three responses were received from HF nurses across Ireland (a 35% response rate). On average, it takes four outpatient titration appointments for HFrEF patients prescribed an ACEi or ARB to reach MTD and three appointments for ARNI. Considering the cost of an outpatient appointment in Ireland as €178, the cost of appointments for ACEi/ARB and ARNI titration is €712 and €534 respectively.

CONCLUSIONS:

More appointments are required to titrate patients to MTD of an ACEi/ARB than ARNI. Currently patients must reach MTD of an ACEi/ARB before initiation of treatment with an ARNI. There is an opportunity to reduce the number of outpatient appointments used for the initiation of sacubitril/valsartan should the treatment be initiated earlier in the pathway. This could free up capacity on the cardiovascular outpatient waiting list and create efficiencies within the healthcare system. The increased cost of ARNI treatment versus that of ACEi/ARB treatment should be considered when calculating the potential cost of any change in policy.