Sector-level disparities in ESC-recommended GDMT implementation for patients with HFrEF: a real-world retrospective comparative study
Reshma Niraula, Raeesah Ajaz, Khatuna Diasamidze, Marine MishvelidzeAbstract
Background
In patients with heart failure with reduced ejection fraction (HFrEF), guideline-directed medical therapy (GDMT) is crucial for reducing morbidity and mortality. The 2023 European Society of Cardiology (ESC) ‘Focused Update’ on heart failure reinforces the ‘Four Pillars’ of HFrEF treatment as Class I recommendations. However, real-world implementation in clinical practice often remains varied across different healthcare sectors.
Purpose
To evaluate adherence to ESC-recommended GDMT in patients with HFrEF and to examine whether there are sector-level differences in implementation between private and public hospitals.
Methods
We conducted a retrospective cross-sectional study of 100 consecutive patients with HFrEF discharged between June 2025 and February 2026. Patients were equally divided between a tertiary public hospital and a tertiary private hospital (n=50 each). Prescription of ACEi/ARB/ARNI, beta-blockers, mineralocorticoid receptor antagonists (MRA), and SGLT2 inhibitors at discharge was recorded. Quadruple therapy (QT) was defined as the prescription of all four drug classes. Relevant demographics and clinical variables, including age, type 2 diabetes mellitus (T2DM), chronic kidney disease (CKD), and NYHA class, were documented. A GDMT score (0–4) was calculated. Group comparisons were performed using chi-square testing.
Results
Between the two cohorts, baseline characteristics were comparable in mean age (73.4 vs 71.6, p=0.38), NYHA class distribution (p=0.36), T2DM prevalence (42% vs 36%, p=0.68) and CKD (4% vs 2%, p=1.00). 54% of patients in the private hospital were prescribed QT, compared with only 22% in the public hospital (p<0.001). The use of SGLT2 inhibitors was significantly higher in the private sector (98% vs 42%, p<0.001), as was MRA prescription (96% vs 78%, p=0.007). We found no substantial differences in ACEi/ARB/ARNI (64% vs 70%, p=0.52) and beta-blockers (80% vs 84%, p=0.50) use. Among patients with diabetes, SGLT2 inhibitors were prescribed in 100% of cases in the private hospital compared with 61.1% in the public hospital (p=0.006). The mean GDMT score was higher in the private hospital (3.38 vs 2.74), reflecting greater overall implementation of guideline-directed therapy.
Conclusion
There are significant differences in how different healthcare sectors apply ESC-recommended GDMT for HFrEF. Despite comparable baseline characteristics, optimal QT was more frequently prescribed to patients with HFrEF in the private hospital. Additionally, SGLT2 inhibitors remain under-prescribed in the public hospital, highlighting an underlying gap and the need for standardised adoption of GDMT. This may reflect variation in access, affordability, or institutional prescribing systems, alongside potential therapeutic inertia. Further large-scale studies and targeted strategies are necessary to ensure equitable delivery of evidence-based heart failure care.GDMT adherence in private vs public hospitalOverall mean GDMT score