Implementation of optimal medical therapy in patients hospitalized for heart failure

Abstract

Introduction: Heart failure is a leading cause of hospitalization and mortality worldwide. Adherence to the European Society of Cardiology (ESC) guidelines can significantly reduce mortality and rehospitalization rates. However, many patients are discharged without optimal guideline-directed therapy. Aim: To evaluate the implementation of the 2021 ESC guidelines (with 2023 updates) for heart failure management in clinical practice. Material and methods: This prospective, observational study included 118 patients hospitalized for acute heart failure from December 1, 2024, to January 31, 2025. Prescription rates at discharge for the four recommended drug classes were assessed: Angiotensin-converting enzyme inhibitors (ACEIs), Angiotensin receptor blockers (ARBs), or Angiotensin receptor neprilysin inhibitors (ARNIs), Beta-blockers (BBs), Mineralocorticoid receptor antagonists (MRAs), Sodium-glucose cotransporter-2 inhibitors (SGLT2Is). Only patients without contraindications were considered eligible. Common clinical reasons for non-prescription were also examined. Results: The ACEI/ARB/ARNI therapy was prescribed to 92.7% of eligible patients, BBs to 79.1%, MRAs to 61.7%, and SGLT2Is to 46.7%. Only 38.1% of the total population received all four drug classes at discharge. Contraindications for ACEI/ARB/ARNI included renal dysfunction, hyperkalemia, and hypotension. The MRAs were limited by renal insufficiency and hyperkalemia. Beta-blockers were often withheld due to bradycardia, asthma, or hypotension. Also, SGLT2Is were avoided in patients with significantly impaired renal function or hypotension. Conclusion: Implementation of guideline-directed therapy in heart failure patients remains suboptimal. Although ACEI/ARB/ARNI therapy showed high adherence, BBs and MRAs were less frequently used, and SGLT2Is were under-prescribed. Greater efforts are needed to improve adherence to ESC recommendations at discharge.