Nurse led titration of guideline-directed medical therapy for heart failure: an operative flow chart

Titration of guideline-directed medical therapy (GDMT) in heart failure (HF) is recommended by current guidelines. Recent data show that titration is not performed in most patients because of barriers related to healthcare systems, patient factors, and therapeutic inertia, leading to worse patient outcomes.

Nurse-led titration of GDMT for HF may increase the uptake of recommended HF therapies and doses. In Italy, only a few seminal experiences regarding multi-professional management of HF therapy have been reported, and huge disparities regarding this issue persist across European countries. This article describes the operational aspects required to implement a nurse-led GDMT titration program. Italian medical–legal aspects are also discussed, and an operational flow chart is provided. The main prerequisites are dedicated training and the adoption of management protocols, which, pending national educational plans and protocols, should start at the level of local institutions. These requirements should be complemented by detailed medical prescriptions specifying, for each patient, the timing and methods of titration, any other assessments to be performed, and the resulting actions.

A multi-professional strategy to manage HF patients involving nurse-led titration of GDMT for HF is suggested as a possible way to improve guideline uptake in real-world practice. This paper aims to describe how to implement it in daily practice in countries such as Italy, where nurse-led titration is not yet standard of care.