Therapeutic inertia in heart failure management: Indian registry evidence and strategies to close the guideline-directed medical therapy prescribing gap

Heart failure (HF) remains a major cardiovascular health burden in India, with substantial mortality, recurrent hospitalization and impaired quality of life, despite the availability of effective disease-modifying therapies. Contemporary Indian registries demonstrate a persistent gap between guideline recommendations and real-world implementation of guideline-directed medical therapy (GDMT), particularly regarding initiation of comprehensive four-pillar therapy, dose optimization and treatment persistence. This review provides a balanced overview of recent advances, controversies, implementation challenges, research gaps and future directions concerning therapeutic inertia in heart failure management within the Indian healthcare setting. Relevant literature was identified through PubMed/MEDLINE, Scopus, Google Scholar, Indian heart failure registries, contemporary consensus statements and international heart failure guidelines. Publications were selected based on relevance to Indian HF epidemiology, GDMT utilization, therapeutic inertia and implementation strategies, with contemporary evidence prioritized and landmark trials included where necessary to establish the evidence base. Available evidence indicates that therapeutic inertia extends beyond failure to prescribe medications and includes delayed initiation, incomplete optimization and inadequate continuation of evidence-based therapy. Patient affordability, physician-related treatment hesitation, fragmented follow-up and healthcare-system limitations collectively contribute to the GDMT prescribing gap. Early initiation of foundational therapies, structured multidisciplinary heart failure care, pharmacist-supported optimization, telehealth and quality-improvement programs represent promising approaches to improve implementation. Future Indian research should focus on pragmatic implementation studies evaluating timely GDMT initiation, four-pillar achievement, dose optimization, persistence and patient-centered clinical outcomes across diverse healthcare settings.