Exploring the perceived barriers and facilitators to guideline directed medical therapy in heart failure

Abstract Background Heart failure (HF) is a progressive condition associated with significant morbidity and mortality. Pharmacological therapy represents the cornerstone of HF management, with evidence of Guideline Directed Medical Therapy (GDMT) demonstrating significant clinical benefits, including reduction in mortality and hospitalisation rates. Despite the evidence that early initiation and optimisation of GDMT significantly improving survival, substantial gaps in implementation and timely dose optimisation persist in routine clinical practice with little understanding of the issues. Purpose To explore the facilitators and barriers to timely GDMT as perceived by HF nurses. Methods In-depth interviews were undertaken with HF nurses in Ireland and thematic analysis performed. Results A total of 12 interviews were undertaken (six Advanced Nurse Practitioners ANP and six Clinical Nurse Specialists CNS) and data saturation achieved. Six themes were identified were (i) Capacity and Workforce Constraints, (ii) Diagnostic & Laboratory Barriers, (iii) Variability in Service Models and Regional Inequity, (iv) Professional Scope, Autonomy & ANP–CNS Role Dynamics, (v) Guideline-Driven Practice & Clinical Leadership and (vi) Patient-Level Barriers (health literacy, socioeconomic issues and misinformation). Across all sites (urban and rural), nurses described staff shortages, excessive caseloads with limited clinic capacity and these factors slowed GDMT titration and restricted follow-up. Dependence on hospital laboratories, potassium transport times, and fragmented ordering systems resulted in avoidable delays, especially in rural areas without Point-Of-Care testing. Nurses repeatedly emphasised that access to blood testing, echocardiography capacity, and laboratory logistics created bottlenecks to safe titration. Differences between CNS and ANP roles where ANPs diagnose and manage complex patients, while CNSs focus on optimisation but workload pressure have blurred the boundaries. Integrated hubs with physiologists, Point-Of-Care blood testing, and electronic patient records deliver faster care than traditional hospital-based services. Despite clear barriers, HF nurses maintained their confidence in prescribing and titration. In relation to patient barriers, nurses identified low health literacy, misinformation, fear of the term "heart failure," and financial challenges as barriers. Nurses universally described their commitment to evidence-based care and were consistently early adopters of the ESC HF guidelines. Conclusion Through the interviews, clear barriers exist including limited staffing, diagnostic barriers, and regional inequities but HF nurses demonstrated their expertise, application of guidelines to clinical practice and commitment to optimising GDMT. These findings highlight a workforce that is clinically skilled, adaptable, and critically aware of system shortcomings, advocating not only for patients but for broader structural reform.