Implementation of Guideline-Recommended Therapies for Patients With Heart Failure and Reduced Ejection Fraction: A Regional Arab Middle East Experience

Abstract

We describe the characteristics of ambulatory patients with heart failure with reduced ejection fraction (HFrEF) in the Gulf region (Middle East) and the implementation of guideline-recommended treatments. We included 2427 HFrEF outpatients (mean age 59 ± 13 years, 75% males and median left ventricular ejection fraction [LVEF] of 30%). A high proportion of patients received guideline-recommended medications (angiotensin-converting enzyme inhibitor [ACEI]/angiotensin receptor blocker [ARB]/angiotensin receptor-neprilysin inhibitor [ARNI] 87%, β-blocker 91%, mineralocorticoid antagonist [MRA] 64%). However, only a minority of patients received guideline-recommended target doses (ACEI/ARB/ARNI 13%, β-blocker 27%, and MRA 4.4%). Old age was a significant independent predictor for not prescribing treatment ( P < .001 for ACEI/ARB/ARNI and MRA; and P = .002 for β-blockers). Other independent predictors were chronic kidney disease (for both ACEI/ARB/ARNI and MRA, P < .001) and higher LVEF ( P = .014 for β-blockers and P < .001 for MRA). Patients with HFrEF managed by heart failure specialists more often received recommended target doses of ACEI/ARB/ARNI (40% vs 11%, P < .001) and β-blockers (56% vs 26%, P < .001) compared to those treated by general cardiologists. Although the majority of our patients with HFrEF received guideline-recommended medications, the doses they were prescribed were suboptimal. Understanding the reasons behind this is important for improved practice.

Clinical Pharmacist’s Intervention to Improve Medication Titration for Heart Failure: First Experience from Sudan

“… 17 Nonetheless, the mean age is about 8 years younger than patients in studies reported from developed countries. 18 This might be due to the younger population structure in Sudan. 19 Etiologically, the major causes of HF were cardiomyopathy and CAD, which are in line with a report about the most prevalent causes of HF in Sudan.…”

Guideline-directed medical therapy in heart failure patients with reduced ejection fraction in Oman: utilization, reasons behind non-prescribing, and dose optimization

“…The Gulf DYSPNEA study 16 of ambulatory HF patients with reduced EF in the Arabian Gulf region reported a prevalence of around 87% and 91% for RAS and beta blockers, respectively. We hypothesized that, based on a prevalence of around 90% for both RAS and beta blockers, a sample size of 138 HFrEF patients with a margin of error of 5% and 95% confidence interval was needed.…”

“…The worldwide prevalence of HF has been increasing steadily, However, these medications are significantly underutilized, not only in North America [8][9][10][11] or Europe, [12][13][14][15] but also in the Middle East. 16,17 A number of studies 13,17 have hypothesized that the underutilization of GDMT could be due to intolerability and contraindications which are not routinely reported. The addition of evidence-based sodium-glucose cotransporter-2 (SGLT2) inhibitors to GDMT therapy, which is reported to reduce cardiovascular deaths and worsening of HF in patients with HFrEF, 18,19 is also recommended irrespective of whether patients have diabetes or not.…”

“…The guidelines [4][5][6] have also recommended maximal appropriate dosing in HF patients to optimize clinical outcomes and this is defined as greater ≥50% of the target GDMT dosing. 20 However, a number of studies, [9][10][11][12][13][14][15] including some in the Middle East, 16,17 have reported suboptimal dosing of HF medications.…”

Application of MAT Methodology in the Evaluation of Prescribing Adherence to Clinical Practice Guidelines for Secondary Prevention of Coronary Heart Disease in Post-Acute Coronary Syndrome Patients in Kuwait

“…In Kuwait, there has been an increased interest in the management of patients with CVD and the provision of evidence-based clinical services by practitioners in recent years ( Zubaid et al, 2020 ; Al-Zakwani et al, 2018 ; Longenecker et al, 2013 ). However, there is a lack of the literature assessing prescribing practices in the management of CVDs by health-care providers.…”