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Vol. 74. Issue 6.
Pages 561 (June 2021)
Vol. 74. Issue 6.
Pages 561 (June 2021)
Letter to the Editor
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Drug titration by nursing professionals in heart failure units
Ajuste de dosis por enfermería en unidades de insuficiencia cardiaca
José Manuel Civera
Corresponding author

Correspondinga author:
, Adriana Conesa, Amparo Villaescusa, Julio Núñez
Unidad de Insuficiencia Cardiaca, Hospital Clínico Universitario de Valencia, Valencia, Spain
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Juana Oyanguren, Lluisa Garcia-Garrido, Magdalena Nebot-Margalef, Pedro Latorre-García, Jesús Torcal-Laguna, Josep Comín-Colet, Julia Roure, José González-Costello, Nicolás Manito, José M. García-Pinilla, Yolanda Sánchez-Paule, Alfonso Varela-Román, María Moure, Javier Segovia-Cubero, Teresa Soria, Eunate Arana-Arri, Iñaki Lekuona
Rev Esp Cardiol. 2021;74:56210.1016/j.rec.2020.10.021
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To the Editor,

We have read with great interest the article by Oyanguren et al.1 on a clinical trial that randomized 320 patients with new-onset heart failure (HF), reduced ejection fraction, and New York Heart Association (NYHA) functional class II-III to drug doses titrated by nursing professionals or by cardiologists. Four months after discharge, the study observed noninferiority in the beta-blocker doses achieved by nurses compared with doses titrated by cardiologists; noninferiority was also seen in the doses achieved for angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and mineralocorticoid receptor antagonists, with the nursing arm achieving even higher target doses of angiotensin-converting enzyme inhibitors.1 In addition, nursing intervention in dose titration did not lead to more adverse events such as mortality and hospitalizations.1 The results of this trial are consistent with other contemporary studies and show that dose titration by trained nurses in HF patients is not only feasible and safe, but may even obtain better results in terms of achieving the maximum tolerable doses.2

Despite the available evidence, the feasibility and implementation of these results in clinical practice vary considerably in Spain, and regulations are often ambiguous. Despite the approval of Royal Decree 1302/2018 of 22 October amending Royal Decree 954/2015 of 23 October regulating the indication, use and authorization for dispensing medicines and medical devices for human use by nurses,3 these decrees continue to emphasize the role of physicians, dentists, and podiatrists as “the only professionals qualified to prescribe medications subject to medical prescription. Without prejudice to the above, nurses shall be able to autonomously indicate, use and authorize the dispensing of all medicines not subject to medical prescription as well as medical devices related to their professional exercise, by means of the respective dispensing order.”3

We consider that the legislative change is positive, although insufficient. Dose titration cannot be discussed without also addressing the topic of prescription. At present, specialist nurses cannot officially titrate doses but can only make recommendations that must then be confirmed by physicians.

The role of nursing professionals in the clinical care of complex chronic patients, such as patients with HF, is indisputable and deserves to be strengthened. Unfortunately, much remains to be done in Spain. First, staff should receive adequate training, an issue that still requires attention. Second, multidisciplinary and collaborative work should be fostered between physicians and nurses within specific health care programs. It is essential to continue making legislative progress which, rather than mere “statements of intent” or a potential source of varying interpretations, should lead to genuine changes at the executive level that, among other aspects, will allow dose titration by specialist nurses trained within clearly established parameters. In European countries, the duties of HF specialist nurses vary greatly according to geographic location.4 Nevertheless, the European Society of Cardiology standards are clear: a main focus of nurses is to optimize medical therapy and to provide patient education.4

The current pandemic is testing our health system, and it has become even clearer that resources are limited. Teams of skilled and specialized staff are needed to manage this new situation. We believe that allowing nursing professionals to perform dose titration will contribute to improving the care of patients with HF and will promote professional development and specialization.5

J. Oyanguren, L. García-Garrido, M. Nebot-Margalef, et al.
No inferioridad de la titulación de enfermera de insuficiencia cardiaca en comparación con la de cardiólogo de insuficiencia cardiaca. Ensayo aleatorizado multicéntrico ETIFIC.
Rev Esp Cardiol., 74 (2021), pp. 533-543
A. Driscoll, J. Currey, A. Tonkin, H. Krum.
Nurse-led titration of angiotensin converting enzyme inhibitors, beta-adrenergic blocking agents, and angiotensin receptor blockers for people with heart failure with reduced ejection fraction.
Cochrane Database Syst Rev., (2015),
Gobierno de España. Agencia Estatal Boletín Oficial del Estado. Real Decreto 1302/2018, de 22 de octubre, por el que se modifica el Real Decreto 954/2015, de 23 de octubre, por el que se regula la indicación, uso y autorización de dispensación de medicamentos y productos sanitarios de uso humano por parte de los enfermeros. Available at: Accessed 22 Sep 2020.
T.A. McDonagh, L. Blue, A.L. Clark, et al.
European Society of Cardiology Heart Failure Association Standards for delivering heart failure care.
Eur J Heart Fail., 13 (2011), pp. 235-241
S. Fernández, I. Lumillo, A. Brugués, et al.
Prescripción enfermera: análisis de concepto.
Aten Primaria., 51 (2019), pp. 245-251
Copyright © 2020. Sociedad Española de Cardiología
Revista Española de Cardiología (English Edition)

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