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Vol. 74. Issue 6.
Pages 562 (June 2021)
Vol. 74. Issue 6.
Pages 562 (June 2021)
Letter to the Editor
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Drug titration by nursing professionals in heart failure units. Response
Ajuste de dosis por enfermería en unidades de insuficiencia cardiaca. Respuesta
Juana Oyangurena,b,
Corresponding author

Corresponding author:
, Lluisa Garcia-Garridoc,d, José González-Costelloe,f, Iñaki Lekuonaa
a Servicio de Cardiología, Hospital Universitario Galdakao-Usansolo, OSI Barrualde-Galdakao-Osakidetza, Servicio Vasco de Salud, Galdakao, Vizcaya, Spain
b BIOCRUCES, Instituto de Investigación Sanitaria, Vizcaya, Spain
c Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Universitario Dr. Josep Trueta, Girona, Spain
d Institut d’Investigació Biomédica de Girona Dr. Josep Trueta (IDIBGI), Girona, Spain
e Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
f Institut d’Investigació Biomédica de Bellvitge (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain
Related content
Rev Esp Cardiol. 2021;74:56110.1016/j.rec.2020.10.013
José Manuel Civera, Adriana Conesa, Amparo Villaescusa, Julio Núñez
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To the Editor,

We appreciate the interest from our colleagues Civera et al. regarding the EFITIC trial.1 We believe, however, that some clarification is required:

The rationale for the study was the lack of adherence to dosage guidelines, as reflected in several articles, often associated with a lack of time rather than changes in the role of nurses.

ETIFIC was the first randomized multicenter trial1 that demonstrated the noninferiority of drug titration (dose adjustment) by heart failure (HF) nurses compared with HF cardiologists. The Cochrane review2 evaluated dose titration by HF nurses compared with primary care physicians.

The nurses in the ETIFIC trial had 400hours of HF training, 2 years of HF experience, and training in dose titration.

Dose titration is not the same as prescribing. ETIFIC established the initial individualized prescription by physicians, including the timing of dose adjustment as shown in figures 2-5 of the article on the study design.3 The nurses adjusted the dose following a very precise protocol, with predetermined autonomy and regular supervision from the cardiologist, but not at every visit (mean number of HF nurse appointments was 6.41±2.82 vs 2.20±1.21 with the cardiologist of the group).1

The protocol was agreed by cardiologists, nurses, and managers from 20 hospitals and 10 autonomous communities and was approved by 20 ethics committees and the Spanish Agency for Medicines and Medical Devices in 2014, when the law was more restrictive than now. Legal reform for dose titration is not necessary. The Law for the Regulation of Health Professionals 44/2003, of 21 November, preface explaining rationale, section II and Royal Decree 1302/2018, of 22 October, heading I, general provisions, establish the resolution of professional competencies through interprofessional agreement. In Spain, dose adjustment by HF nurses was a reality before the study and continues to be so.

The current legal framework, with the scientific support of ETIFIC, allows the option to titrate the dose safely and effectively as long as the conditions of the study are met: the nurses are trained, experienced, and have time, there is support from a cardiologist, screening for the procedure, and interprofessional agreement.

Ideally, quality indicators of the drug titration process would be determined by the Spanish Society of Cardiology or Spanish Association of Cardiology Nursing, whichever corresponds to the organization. From our perspective, the major benefits of optimizing drugs, confirmed in the ETIFIC trial (table 3 and Figure 4 of the study1), indicate that it is imperative that we adapt the process so that it is carried out in the safest possible way.

J. Oyanguren, L. Garcia-Garrido, M. Nebot-Margalef, et al.
Noninferiority of heart failure nurse titration versus heart failure cardiologist titration.
ETIFIC multicenter randomized trial. 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., 12 (2015), pp. CD009889
J. Oyanguren, L. Garcia-Garrido, M. Nebot-Margalef, et al.
ETIFIC research group, Design of a multicentre randomized controlled trial to assess the safety and efficacy of dose titration by specialized nurses in patients with heart failure. ETIFIC study protocol.
ESC Heart Fail., 4 (2017), pp. 507-519
Copyright © 2020. Sociedad Española de Cardiología
Revista Española de Cardiología (English Edition)

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