Clinical barriers to the implementation of guideline directed medical therapy in heart failure with reduced ejection fraction

Abstract

Background: Guideline Directed Medical therapy (GDMT) is the foundation of management of heart failure with reduced ejection fraction (HFrEF). But, non- implementation is a concern, and the clinical barriers responsible for this observation are not well documented in our locale.
Objective: To determine the common clinical barriers to the implementation of GDMT in patients with HFrEF, and the correlates.
Methods: This was a retrospective study of hospitalized patients with HFrEF. Data were extracted from the records. The GDMT were Beta blockers (BB), inhibitors of the renin angiotensin aldosterone system (RAAS), and sodium - glucose cotransporter 2 inhibitor
(SGLT2I). The barriers to implementation were determined by the presence of contraindications to the medications, and the correlates of clinical barriers or nonimplementation were determined.
Results: There were 95 cases of HFrEF, and 51(53.7%) were males. The mean age, left ventricular ejection fraction (LVEF), and systolic blood pressure were 59 ± 17.6 years, 32.23 ± 4.9 %, and 117.39 ± 19.3mmHg, respectively. Clinical barriers (CB) were detected in 36
(37.9 %) of cases. The contraindications to GDMT were bradycardia 5 (5.3%), renal dysfunction 8 (8.4 %), asthma 3(3.2 %), hypotension 13(13.7 %), hyperkalemia 5 (5.3%), and history of intolerance 2 (2.1%). Association between clinical barriers, and etiology of HF (dilated cardiomyopathy) gave a p value of 0.007.
Conclusion: Hypotension, and renal dysfunction are the common clinical barriers to the implementation of GDMT, and they correlate with dilated cardiomyopathy. These barriers should therefore be explored before administration of GDMT, and safer alternative therapies considered in affected patients.