Feasibility of inhospital initiation of guideline-directed medical therapy for patients admitted with heart failure with reduced ejection fraction and its clinical outcome at 6 months

ABSTRACT Background: Heart failure with reduced ejection fraction (HFrEF) is associated with high morbidity and mortality, and optimal management requires the timely initiation and uptitration of guideline-directed medical therapy (GDMT). Despite strong recommendations, real-world achievement of target doses for core GDMT agents remains suboptimal. This study aimed to evaluate the implementation and impact of a structured GDMT protocol among patients admitted with HFrEF in a tertiary care setting. Methods: A prospective observational study was conducted over 18 months at the Department of Cardiology, Government Medical College, Kozhikode. Adult patients (≥18 years) with left ventricular ejection fraction < 40% and without significant valvular disease or reversible causes were consecutively enrolled. Patients were initiated on GDMT during hospitalization and followed up at 2 weeks, 4 weeks, and 6 months. Data on drug initiation, dose titration, New York Heart Association (NYHA) class, rehospitalization, and mortality were collected using a structured pro forma. Descriptive and inferential statistics were used to assess target dose achievement and clinical outcomes across four patient groups categorized by the number of drugs received. Results: Of the 98 patients enrolled, 41 (41.84%) received all four GDMT drugs (Group 1), of which 37 (90.24%) achieved target dose, while 26 (26.53%) received three drugs (Group 2), of which 22 (84.62%) received target dose, 20 (20.41%) received two drugs (Group 3), and 11 (11.22%) received only one drug (Group 4). Clinical improvement in NYHA class was significantly higher in Groups 1 and 2 ( P < 0.001). Rehospitalization at 6 months was lowest in Group 1 (31.71%) and highest in Group 4 (72.73%). Mortality was significantly higher in Group 4 (54.54%), P < 0.001. Target dose achievement was strongly associated with improved functional class, lower rehospitalization, and reduced mortality. Conclusions: A structured, protocol-based GDMT implementation strategy during hospitalization and early follow-up significantly improved target dose achievement in HFrEF patients. Higher rates of target dose attainment were associated with better 6-month outcomes, including symptom improvement, fewer rehospitalizations, and lower mortality. These findings underscore the importance of early initiation and uptitration of GDMT to improve heart failure outcomes in routine clinical practice.