RESUMEN
Guideline-directed medical therapy utilization in patients with heart failure with reduced ejection fraction (HFrEF) remains low despite benefits in morbidity and mortality. The authors describe a unique quality improvement initiative designed to increase angiotensin receptor-neprilysin inhibitor (ARNI) and mineralocorticoid receptor antagonist (MRA) utilization in outpatients with HFrEF in a large cardiology practice, whereby eligible patients were identified in a standardized review process and medication utilization rates were linked to group quality metrics. Eligible HFrEF patients were defined as having a left ventricular ejection fraction (LVEF) ≤40% and NYHA functional class II to IV level of symptoms. Those with an LVEF >40%, no documented LVEF, or with NYHA functional class I symptoms were excluded. ARNI utilization was defined as any dose of sacubitril/valsartan prescribed, and MRA utilization was defined as any dose of either spironolactone or eplerenone prescribed. Group quality metric targets were set at >25% ARNI prescription and >60% MRA prescription in eligible patients. Following project implementation, ARNI utilization rose from 31% to 67% and MRA increased from 28% to 66%. Establishing clear quality metrics and formulating a proactive evaluation process was associated with a significant increase in prescription rates.
RESUMEN
In brief The case of an asymptomatic 21-year-old male college sprinter demonstrates that aortic insufficiency may go undiagnosed despite severe underlying cardiac pathology: A murmur detected during the preparticipation exam was the first sign. Activity modification was an important initial intervention. Echocardiography documented severe aortic regurgitation. An exercise multiple gated acquisition (MUGA) scan identified abnormal ejection fractions. After valve replacement, the patient's return to competition was guided by echocardiography, exercise testing, and input of the medical team and family.