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Underutilization of Guideline-Directed Medical Therapy in Heart Failure With Reduced Ejection Fraction: A
Koushik Sanku1, Sanskrita Nemalikanti2, Oluwatobi Adegbile3,4
1Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach, USA.
Cureus
|October 6, 2025
Summary
Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) is underutilized, especially mineralocorticoid receptor agonists (MRA). Targeted interventions are needed to improve GDMT adherence and optimize heart failure care.
Area of Science:
- Cardiology
- Pharmacology
- Internal Medicine
Background:
- Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) comprises ACEI/ARB/ARNI, beta-blockers, MRA, and SGLT2i.
- Despite proven mortality benefits, GDMT implementation in HFrEF remains suboptimal.
Purpose of the Study:
- To assess GDMT utilization and dosing patterns in an HFrEF patient cohort.
- To identify patient characteristics associated with GDMT use and optimization.
Main Methods:
- Retrospective observational study of 236 HFrEF patients (EF ≤40%) across three outpatient clinics.
- Assessment of GDMT use and dosing (<50%, ≥50 to <100%, 100% target dose) for beta-blockers, ACEI/ARB/ARNI, MRA, and SGLT2i.
- Logistic regression analysis to examine patient characteristics and treatment patterns.
Main Results:
- Low rates of target-dose GDMT: beta-blockers (16.5%), ACEI/ARB/ARNI (10.2%), MRA (31.4%), SGLT2i (42.8%).
- Quadruple therapy achieved by only 21.2%; <1% on target doses for all four classes.
- MRA use was notably low (58.9% not on therapy); predictors for MRA use included lower SBP, non-ischemic cardiomyopathy, obesity, and absence of AF.
- SGLT2i use more common in younger patients with lower EF and SBP; T2DM strongly predicted SGLT2i initiation and optimization.
Conclusions:
- Significant gaps exist in GDMT implementation for HFrEF patients.
- MRA use is particularly limited despite its benefits and affordability.
- Targeted interventions are crucial to improve GDMT initiation and optimization, potentially reducing disparities in heart failure care.
Keywords:
angiotensin receptor-neprilysin inhibitor (arni)angiotensin-converting enzyme inhibitors (acei)angiotensin-ii receptor blocker (arb)beta-blockerschronic heart failureguideline-directed medical therapy (gdmt)hfrefmineralocorticoid receptor antagonistrenin-angiotensin-aldosterone system (raas)sglt2-inhibitors
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