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Nurse-led titration of CHF drugs better than doctors?

Nurse-led titration of CHF drugs better than doctors?

Publication date: Tuesday, 05 July 2016
Contributor(s): Jeremy Bray

A new Cochrane Review highlights the value of nurse-led titration of ACE inhibitors, beta-blockers and angiotensin II receptor blockers (ARBs) in patients with chronic heart failure (CHF). All-cause mortality and hospitalisations were lower in the nurse-led titration group compared with the usual care of titration by GPs.

Seven randomised controlled trials were identified that titrated CHF drugs in 1684 adults with CHF due to left ventricular systolic dysfunction. Nurse-led titration took place in an outpatient clinic in 4 studies; the other studies included nurse-led titration in primary care, via telephone follow-up and in a residential care facility. Follow-up ranged from 6 months to 18 months.

In a pooled meta-analysis of 4 of the studies (3 on beta-blockers and 1 on beta-blockers and ACE inhibitors, n=560), nurse-led titration was associated with a lower risk of hospital admission for any cause than titration by a doctor (RR=0.80, 95% CI 0.72 to 0.88, p=0.000022). Nurse-led titration was also associated with a lower rate of hospital admission related to heart failure (RR=0.51, 95% CI 0.36 to 0.72, p=0.00012; 2 studies on beta-blockers and 2 on beta-blockers and ACE inhibitors, n=642).

Meta-analysis of 6 studies (n=902) showed that people who received nurse-led titration were less likely to die from any cause than those who had titration by a doctor (RR=0.66, 95% CI 0.48 to 0.92, p=0.015). The authors estimated that approximately 56 deaths could be avoided in every 1000 people if everyone with heart failure had nurse-led titration of their drug doses.

However, these findings are limited by the lack of data on the number of participants who achieved target dose and on the frequency of adverse events, or from low quality evidence.

Current NICE guidance on CHF
  • The NICE guideline on chronic heart failure in adults recommends offering ACE inhibitors and beta-blockers to all people with heart failure due to left ventricular systolic dysfunction. Clinical judgement should be used when deciding which drug to start first.
  • Therapy with ACE inhibitors should be started at a low dose and titrated upwards at short intervals (for example, every 2 weeks) until the optimal tolerated or target dose is achieved. Beta-blockers should be introduced in a ‘start low, go slow’ manner.
  • An ARB may be considered as an alternative for people intolerant to an ACE inhibitor or who remain symptomatic despite optimal therapy with an ACE inhibitor and a beta-blocker.
  • The NICE pathway on chronic heart failure brings together all related NICE guidance and associated products on the condition in a set of interactive topic-based diagrams.


This Cochrane review highlights the value of nurse-led titration in CHF. Nurse-led clinics in heart failure may lead to optimisation of treatment, but more robust studies are required to examine safety and cost effectiveness before this strategy can be recommended over usual care.

Driscoll A et al. Nurse led titration of ACE inhibitors, beta-adrenergic blocking agents and angiotensin receptor blockers for people with heart failure with reduced ejection fraction. Cochrane Database of Systematic Reviews 2015; DOI: 10.1002/14651858.CD009889.pub2

Topics covered:
Category: Evidence in Practice
Edition: Volume 1, Number 7, BJPCN Online 2016
Contributor(s): Jeremy Bray

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