Implementation of Guideline-Directed medical therapy and factors in heart failure with reduced ejection fraction

Abstract Background To evaluate the implementation of guideline-directed medical therapy and identify associated clinical factors among patients with heart failure with reduced ejection fraction (HFrEF) receiving follow-up at Asella Referral and Teaching Hospital, Ethiopia. Methods We conducted a hospital-based cross-sectional study involving 156 patients with HFrEF attending follow-up at Asella Referral and Teaching Hospital from October to December 2023. Eligible participants were adults with LVEF ≤ 40%, ≥ 6 monthly clinic visits, and a recent echocardiogram within two years. Data were collected through structured interviews and chart review and analyzed using SPSS version 26. Results Prescription rates for renin-angiotensin system inhibitors (RASI), beta-blockers, and mineralocorticoid receptor antagonists (MRA) were 98.1%, 96.8%, and 70.5%, respectively. However, only 30.8% achieved target doses of RASI, 1.3% for beta-blockers, and 67.3% for MRA. Only 1.3% were on all three therapies at guideline-recommended target doses. No patient received angiotensin receptor–neprilysin inhibitors (ARNI) or sodium-glucose co-transporter 2 inhibitors (SGLT2i), primarily due to cost and availability. In multivariable analysis, baseline bradycardia (adjusted odds ratio AOR 13.7; 95% CI 1.8–100.3; p = 0.010) and diabetes mellitus (AOR 4.5; 95% CI 1.13–17.9; p = 0.033) were significantly associated with achieving RASI target doses. Absence of prior heart failure hospitalization was associated with a lower likelihood of achieving the MRA target dose (AOR 0.4; 95% CI 0.18–0.9; p = 0.029). Conclusion The implementation of guideline-directed medical therapy in HFrEF patients was suboptimal, with only 1.3% achieving target doses of all three available therapies. No patients received ARNI or SGLT2 inhibitors due to availability and cost barriers. Key clinical factors such as baseline heart rate, diabetes, and hospitalization history influenced medication optimization. GDMT optimization in HFrEF remains inadequate in Ethiopia. Policy interventions (e.g., formulary expansion) and structured titration protocols are urgently needed.