Bridging evidence and practice in heart failure care: barriers and pragmatic solutions to guideline-directed medical therapy implementation in India and other low-resource settings

Heart failure with reduced ejection fraction (HFrEF) remains a leading cause of morbidity, hospitalization, and mortality in low- and middle-income countries (LMICs). Guideline-directed medical therapy (GDMT) including angiotensin receptor-neprilysin inhibitors (ARNIs), evidence-based beta-blockers, mineralocorticoid receptor antagonists (MRAs), and sodium–glucose co-transporter 2 (SGLT2) inhibitors has consistently demonstrated reductions in mortality and heart failure (HF) hospitalizations. Despite strong evidence, real-world implementation of GDMT in LMICs remains suboptimal. This article synthesizes published evidence and expert experience to identify barriers to GDMT implementation in India and comparable LMIC settings and to propose pragmatic, resource-aligned strategies to improve uptake. Relevant English-language literature (2015–2025) was identified through PubMed, Google Scholar, and guideline repositories (ESC, ACC/AHA/HFSA, CSI). Search terms included “heart failure,” “GDMT,” “LMIC,” “India,” “implementation barriers,” and “pharmacist-led care.” Key guidelines, randomized trials, observational studies, registries, and relevant reviews were included. Barriers span economic constraints, limited insurance coverage, high out-of-pocket costs, low health literacy, cultural beliefs, fragmented follow-up, limited access to specialized HF services, inconsistent drug availability, and clinician-level knowledge-practice gaps. Evidence from observational studies and implementation reports supports early low-dose combination GDMT, simplified titration pathways, pharmacist- and nurse-led follow-up models, task-shifting, and telemedicine-enabled monitoring as feasible strategies in LMIC settings. Bridging the evidence-practice gap for GDMT in LMICs requires coordinated, multi-level interventions tailored to resource constraints. Strengthening team-based care and aligning policy with essential HF therapies can substantially improve outcomes and equity.