Role of the Ghanaian Clinical Pharmacist in Providing Evidence-based Pharmacotherapy for Heart Failure Patients: The Way Forward

Background: Heart failure is extensively characterized as a disorder arising from a complex interaction between impaired ventricular performance and neurohormonal activation. In order to achieve optimal therapeutic outcomes, all heart failure patients must be managed by a multidisciplinary team of healthcare providers, using evidence-based Pharmacotherapy. Purpose: The aim of this article is to assess the clinical role of the Ghanaian Pharmacists in optimizing Pharmacotherapy for heart failure patients based on internationally established clinical roles of Pharmacists. Methods: A literature search was conducted via google scholar using the “search engine” terms: Pharmacist, Clinical Role, Heart failure to look for all studies published in English. The search revealed a total of 98 studies. Only the studies that discussed the role of the clinical Pharmacists specific to heart failure or generally for patients with cardiovascular diseases were included; All other studies were excluded. A Total of 54 studies were used for data analysis. Clinical Pharmacists who are somehow involved in the management of heart failure patients were interviewed to ascertain their roles as members of a multidisciplinary team and their responses documented. Conclusions: A Multidisciplinary team approach including a Clinical Pharmacists with expertise in cardiovascular therapeutics, is required in the management of heart failure patients in order to improve therapeutic outcomes. The current clinical role of the Ghanaian Pharmacist in the management of heart failure patients is substandard.


Introduction
Heart Failure is a low cardiac output disease that can either manifests itself acutely or chronically and is characterized as a disorder arising from a complex interaction between impaired ventricular performance and neurohormonal activation [1]. Clinical Pharmacists possess advanced training, certification and experience in a specific practice setting and or disease; and are usually important members of a multidisciplinary team of healthcare providers [2][3][4][5] Clinical Pharmacists caring for heart failure patients provide optimized evidence-based Pharmacotherapy which improves therapeutic outcomes [6] Despite available evidence supporting the mortality benefits provided by some prescribed therapies for heart failure, it is well documented that, these therapeutic options are not optimally prescribed in real clinical practice [7]. This creates an opportunity for Clinical pharmacists to recommend drug therapy interventions that will maximize outcomes. Clinical Pharmacists Responsibilities in the management of heart failure patients are diverse and well documented in the literature [8]. Although each practice environment creates a peculiar opportunity for different types of clinical pharmacist's interventions, there are a few important aspects of services that appear to be consistently performed across different practice settings [9]. The aim of this article is to assess the clinical role of the Ghanaian Pharmacists in optimizing Pharmacotherapy for heart failure patients based on the internationally established clinical roles for Pharmacists.

Methods
A literature search was conducted via google scholar using the "search engine" terms: Pharmacist, Clinical Role, Heart failure looking for all studies published in English. The search revealed a total of 98 studies. Only the studies that discussed the role of the clinical Pharmacists specific to heart failure or generally in patients with cardiovascular diseases were included, all other studies were excluded. A Total of 54 studies were used for data analysis. Clinical Pharmacists who are somehow involved in the management of heart failure patients were interviewed to ascertain their roles as members of a multidisciplinary team and their responses documented.

Results
As it is common with all clinical Pharmacists in general, the aim of the heart failure clinical pharmacist is to identify and resolve any drug therapy problems associated with anti-heart failure Pharmacotherapy. Table 1. Summarizes the internationally established the general drug therapy problems categories with pertinent examples in heart failure patients [10][11][12][13]. Several studies have been conducted to assess the impact of clinical Pharmacists interventions on outcomes in the management of heart failure patients. These studies described the role of pharmacists in the management of patients with heart failure; and discussed various services performed by pharmacists in diverse spectrum in different practice settings, using several outcomes measure. The content of Table 2 depicts a summary of some of the relevant trials evaluating Pharmacists intervention in heart failure [13][14][15][16][17][18][19][20][21][22][23][24][25][26]. Jain et al. [15] Outpatient clinic service Before and after intervention comparison a) Dose titration of heart failure medications based on a protocol b) By pharmacist or nurse a) Improvement in drug prescribing rate b) Improvement in target dose b) achievement c) Improvement in symptoms

Intentionally established roles of the clinical Pharmacists in the management of heart failure patients
Clinical Pharmacists Provide evidence-based Pharmaceutical care for patients with heart failure through numerous drug therapy interventions [27].

Medication reconciliation and education
Medication reconciliation is a process of comparing patients medications orders to all of the medications that they may have been taking in order to avoid errors such as omissions, duplications, dosing errors and interactions especially during transition of care [28]. Medication reconciliation and education constitute 2 major responsibilities of clinical Pharmacists that are now established to positively impact clinical outcomes of patients with different diseases including heart failure patients [29].
Complex medication regimens for heart failure coupled with other comorbidies increase the likelihood of medication reconciliation discrepancies. Clinical Pharmacists leading the medication reconciliation process, perform medication reviews, communicate prescribing errors with the cardiologist, prepare written overviews of discharge medications and communicate with community pharmacists and patients primary care physicians about their medications in order to establish continuum of care so as to significantly reduce medication discrepancies [30][31][32][33][34][35][36][37][38][39][40].
Medication initiation, dosage titration, adjustment and monitoring.
Although several evidence-based clinical practice guidelines have established that treatment of heart failure patients with certain drug therapies improve mortality [41][42][43][44][45], these therapies are suboptimally prescribed. Therefore, under these compromising circumstances, Clinical Pharmacists seize the opportunity to initiate therapies that are omitted, recommend titration of improper dosages, make recommendations for adjustment of dosages of certain therapies, implement therapeutic drug monitoring protocols for some therapies; all based on functional integrity of certain vital organs [46]. This approach definitely optimizes therapeutic outcomes.
Post Hospital discharge follow up clinic or home visit The involvement of clinical Pharmacists in the management of heart failure patients in the "outpatients" or "post-discharge" settings, is perhaps the most researched and documented [47]. During post hospital discharge follow up visits, Clinical Pharmacists perform an assessment of the patient's knowledge about prescribed medications, screen for all possible interactions, adverse drug reactions and ease of access to prescribed heart failure medication. This type of patient centered care has the potential to reduce the rate of hospital readmission due to decompensated heart failure, promotes patients' compliance, and enhance medication safety and effectiveness.

Assessment of the current role of the Ghanaian Clinical Pharmacists in the management of heart failure patients
Currently there are a very limited number of Ghanaian clinical Pharmacists with expertise in cardiovascular therapeutics providing evidence-based Pharmacotherapy for heart failure patients. The depth of clinical services provided by Ghanaian Pharmacists to heart failure patients is considered substandard (20%) as compared to international standards (Table 3). This very limited clinical role will definitely not yield any clinically meaningful and measurable therapeutic outcomes.

Limitations
Since we limited our search engine to only studies published in the English, is it highly likely that we might have missed out on pertinent studies published in non-English languages which could have potentially add more scientific value to the content of this manuscript. Also, the nature of this research did not allow us to assess the impact of the substandard role of the Ghana clinical on morbidity and mortality in heart failure patients. Further research is required in this area.

Conclusion
A Multidisciplinary team approach including a Clinical Pharmacists with expertise in cardiovascular therapeutics, is required in the management of heart failure patients in order to improve therapeutic outcomes. The current clinical role of the Ghanaian Pharmacist in the management of heart failure patients is substandard.

Source of Funding
Not applicable.

Data Availability Statement
Not applicable.

Authors Contributions
The research idea was coined by MMDM and accepted by all authors putting the topic through a re-wording analysis. BBA and KA conducted a very comprehensive literature search and the selected studies were reviewed, synthetized and analyzed by all authors. The manuscript was written by MMDM, revised and approved by all authors.

Declaration of Conflict of Interest
The authors declare that they have no competing interests.