Prescribing pattern, appropriateness, and factors influencing medication use in heart failure patients with reduced ejection fraction at a private tertiary hospital in Malaysia
Main Article Content
Keywords
Adherence, ejection fraction, heart failure, inappropriate medication, medical therapy, target dose
Abstract
Background: Heart Failure with Reduced Ejection Fraction (HFrEF) is a prevalent and serious medical condition worldwide. It affects millions of people and contributes significantly to morbidity and mortality. Inappropriate use of the medications may lead to adverse health outcomes and treatment failure. Objectives: This study aimed to assess prescribing patterns, the prevalence of potentially inappropriate medications (PIMs), the proportion of patients receiving the target guideline-directed medical therapy (GDMT) dose, and factors associated with suboptimal dosing in patients with HFrEF at a private tertiary care hospital in Malaysia. Methodology: This retrospective observational study involved 118 Malaysian adult patients with HFrEF who attended at least two outpatient cardiology appointments at the study hospital. The study reviewed prescriptions to identify drug prescribing patterns, GDMT use, target dose attainment, and prescribing of PIM. Results: The cohort was primarily comprised of Chinese individuals (84.80%) and males (78.80%), with a mean age of 58.7 years. The majority of patients (51.70%) received a combination of three GDMT drugs. Only 23.70% of patients were prescribed all four GDMT drugs, with 82.14% of these patients achieving at least one drug at the target dose. The prescribing rates of Renin-Angiotensin-Aldosterone System (RAAS) inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and Sodium-Glucose Cotransporter-2 (SGLT-2) inhibitors were 98.31%, 72.97%, 48.31%, and 78.81%, respectively. The attainment of target doses was low, with only 11.21% reaching the target for RAAS inhibitors, 2.32% for beta-blockers, and 1.89% for MRAs. The study indicated no significant association between target dose attainment and clinical factors, except for betablockers in atrial fibrillation and SGLT-2 inhibitors in diabetes mellitus. Additionally, 4.24% of patients were prescribed PIM. Conclusion: Both adequate prescribing rates and target dose attainment of GDMT remain challenging in clinical practice, underscoring the need for strategies to improve adherence and enhance patient outcomes.
References
1. Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW; ACC/AHA Joint Committee Members. 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18). doi:10.1161/cir.0000000000001063.
2. National Heart Association of Malaysia. Clinical practice guidelines: Management of heart failure. 5th ed. Kuala Lumpur, Malaysia: National Heart Association of Malaysia; 2023.
3. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599–3726. doi:10.1093/eurheartj/ehab368.
4. Balakumaran K, Patil A, Marsh S, Ingrassia J, Kuo CL, Jacoby DL, Arora S, Soucier R. Evaluation of a guideline-directed medical therapy titration program in patients with heart failure with reduced ejection fraction. Int J Cardiol Heart Vasc. 2019;22:1–5. doi:10.1016/j.ijcha.2018.10.003.
5. Seo WW, Park JJ, Park HA, Cho HJ, Lee HY, Kim KH, Yoo BS, Kang SM, Baek SH, Jeon ES, Kim JJ, Cho MC, Chae SC, Oh BH, Choi DJ. Guideline-directed medical therapy in elderly patients with heart failure with reduced ejection fraction: A cohort study. BMJ Open. 2020;10(2). doi:10.1136/bmjopen-2019-030514.
6. Bassi NS, Ziaeian B, Yancy CW, Fonarow GC. Association of optimal implementation of sodium-glucose cotransporter 2 inhibitor therapy with outcome for patients with heart failure. JAMA Cardiol. 2020;5(8):948. doi:10.1001/jamacardio.2020.0898.
7. Vaduganathan M, Claggett BL, Jhund PS, Cunningham JW, Ferreira JP, Zannad F, Packer M, Fonarow GC, McMurray JJV, Solomon SD. Estimating lifetime benefits of comprehensive disease-modifying pharmacological therapies in patients with heart failure with reduced ejection fraction: A comparative analysis of three randomised controlled trials. Lancet. 2020;396(10244):121–128. doi:10.1016/S0140-6736(20)30748-0.
8. Komajda M, Anker SD, Cowie MR, Filippatos GS, Mengelle B, Ponikowski P, Tavazzi L; QUALIFY Investigators. Physicians’ adherence to guideline-recommended medications in heart failure with reduced ejection fraction: Data from the QUALIFY global survey. Eur J Heart Fail. 2016;18(5):514–522. doi:10.1002/ejhf.510.
9. Greene SJ, Butler J, Albert NM, DeVore AD, Sharma PP, Duffy CI, Hill CL, McCague K, Mi X, Patterson JH, Spertus JA, Thomas L, Williams FB, Hernandez AF, Fonarow GC. Medical therapy for heart failure with reduced ejection fraction: The CHAMPS registry. J Am Coll Cardiol. 2018;72(4):351–366. doi:10.1016/j.jacc.2018.04.070.
10. Teng TK, Tromp J, Tay WT, Anand I, Ouwerkerk W, Chopra V, Wander GS, Yap JJ, MacDonald MR, Xu CF, Chia YM, Shimizu W; ASIAN-HF Investigators; Richards AM, Voors AA, Lam CSP. Prescribing patterns of evidence-based heart failure pharmacotherapy and outcomes in the ASIAN-HF registry: A cohort study. Lancet Glob Health. 2018;6(9). doi:10.1016/S2214-109X(18)30306-1.
11. Shahid I, Khan MS, Fonarow GC, Butler J, Greene SJ. Bridging gaps and optimizing implementation of guideline-directed medical therapy for heart failure. Prog Cardiovasc Dis. 2024;82:61–69. doi:10.1016/j.pcad.2024.01.008.
12. Mohd Ghazi A, Teoh CK, Abdul Rahim AA. Patient profiles and outcomes in patients hospitalized for heart failure: A 10-year history of the Malaysian population. ESC Heart Fail. 2022;9(4):2664–2675. doi:10.1002/ehf2.13992.
13. Bermingham M, Ryder M, Travers B, Edwards N, Lalor L, Kelly D, Gallagher J, O’Hanlon R, McDonald K, Ledwidge M. The St Vincent’s potentially inappropriate medicines study: Development of a disease-specific consensus list and its evaluation in ambulatory heart failure care. Eur J Heart Fail. 2014;16(8):915–922. doi:10.1002/ejhf.132.
14. Ling HS, Chung BK, Chua PF, Gan KX, Ho WL, Ong EYL, Kueh CHS, Chin YP, Fong AYY. Acute decompensated heart failure in a non-cardiology tertiary referral centre, Sarawak General Hospital (SGH-HF). BMC Cardiovasc Disord. 2020;20(1):511. doi:10.1186/s12872-020-01793-7.
15. Raja Shariff RE, Kasim S, Borhan MK, Yusoff MR. Acute heart failure – The ‘real’ Malaysian experience: An observational study from a single non-cardiac centre. Proc Singapore Healthc. 2020;30(3):1–7. doi:10.1177/2010105820978664.
16. Zainal Abidin HA, Isa MR, Mohd Arshad MK, Ibrahima ZO, Ibrahima KS, Ismaila JR, Chuaa N, Najme Khira R, Lima CW, Abd Rahmana E, Kasim S. Guideline adherence to prescription in heart failure population in North Kuala Lumpur region. Int J Cardiol. 2017;249(15):s38. doi:https://doi.org/10.1016/j.ijcard.2017.09.135.
17. Shariff RE, Koh HB, Sabian IS, Quah WJ, Ong SH, Sulong MA, Jaafar J, Devi ST, Chan JAW, Abdul Rahim AA, Teoh CK, Mohd Ghazi A. The first Malaysian multidisciplinary team heart failure clinic: A tertiary cardiac centre experience. J Asian Pacific Soc Cardiol. 2023;2:e09. doi:https://doi.org/10.15420/japsc.2022.38.
18. Wan Ahmad WA, Abdul Ghapar AK, Zainal Abidin HA, Karthikesan D, Ross NT, S K Abdul Kader MA, Loch A, Mahendran K, Ramli AW, Ong TK, Mohd Amin NH, Lee CY, Che Hassan HH, Zainal Abidin SK, Liew HB, Ho WS, Mohd Ghazi A. Characteristics of patients admitted with heart failure: Insights from the first Malaysian Heart Failure Registry. ESC Heart Fail. 2024;11(2):727–736. doi:10.1002/ehf2.14608.
19. Lee SE, Lee HY, Cho HJ, Choe WS, Kim H, Choi JO, Jeon ES, Kim MS, Kim JJ, Hwang KK, Chae SC, Baek SH, Kang SM, Choi DJ, Yoo BS, Kim KH, Park HY, Cho MC, Oh BH. Clinical characteristics and outcome of acute heart failure in Korea: Results from the Korean Acute Heart Failure Registry (KorAHF). Korean Circ J. 2017;47(3):341–353. doi:10.4070/kcj.2016.0419.
20. Zhang Y, Gao C, Greene SJ, Greenberg BH, Butler J, Yu J, Zheng Z, Ma G, Wang L, Yang P, Ji X, Xu D, Wang J, Zhang Y, Liu Y, Zhao Y, Qi H, Zhai M, Feng J, Huang Y, Zhou Q, Zhang J. Clinical performance and quality measures for heart failure management in China: the China-Heart Failure registry study. ESC Heart Fail. 2023;10(1):342–352. doi:10.1002/ehf2.14184.
21. Tsuchihashi-Makaya M, Hamaguchi S, Kinugawa S, Yokota T, Goto D, Yokoshiki H, Kato N, Takeshita A, Tsutsui H; JCARE-CARD Investigators. Characteristics and outcomes of hospitalized patients with heart failure and reduced vs preserved ejection fraction. Circ J. 2009;73(10):1893–1900. doi:10.1253/circj.cj-09-0254.
22. Wang CC, Chang HY, Yin WH, Wu YW, Chu PH, Wu CC, Hsu CH, Wen MS, Voon WC, Lin WS, Huang JL, Chen SM, Yang NI, Chang HC, Chang KC, Sung SH, Shyu KG, Lin JL, Mar GY, Chan KC, Kuo JY, Wang JH, Chen ZC, Tseng WK, Cherng WJ. TSOC-HFrEF Registry: A registry of hospitalized patients with decompensated systolic heart failure. Acta Cardiol Sin. 2016;32(4):400–411. doi:10.6515/acs20160704a.
23. Tavazzi L, Senni M, Metra M, Gorini M, Cacciatore G, Chinaglia A, Di Lenarda A, Mortara A, Oliva F, Maggioni AP; IN-HF Outcome Investigators. Multicenter prospective observational study on acute and chronic heart failure: one-year follow-up results of IN-HF outcome registry. Circ Heart Fail. 2013;6(3):473–481. doi:10.1161/CIRCHEARTFAILURE.112.000161.
24. Anis-Syakira J, Jawahir S, Abu Bakar NS, Mohd Noh SN, Jamalul-Lail NI, Hamidi N, Sararaks S. Factors affecting the use of private outpatient services among the adult population in Malaysia. Int J Environ Res Public Health. 2022;19(20):13663. doi:10.3390/ijerph192013663.
25. National Health and Morbidity Survey (NHMS) 2023: Non-communicable diseases and healthcare demand - Key findings. Shah Alam, Malaysia: Institute for Public Health; 2024.
26. Powell-Wiley TM, Poirier P, Burke LE, Després JP, Gordon-Larsen P, Lavie CJ, Lear SA, Ndumele CE, Neeland IJ, Sanders P, St-Onge MP. Obesity and cardiovascular disease: A scientific statement from the American Heart Association. Circulation. 2021;143(21):e984–e1010. doi:10.1161/CIR.0000000000000973.
27. Bragazzi NL, Zhong W, Shu J, Abu Much A, Lotan D, Grupper A, Younis A, Dai H. Burden of heart failure and underlying causes in 195 countries and territories from 1990 to 2017. Eur J Prev Cardiol. 2021;28(15):1682–1690. doi:10.1093/eurjpc/zwaa147.
28. AlHabeeb W, Alayoubi F, Hayajneh A, Ullah A, Elshaer F. A strategy to improve adherence to guideline-directed medical therapy and the role of the multidisciplinary team in a heart-failure programme. Cardiovasc J Afr. 2024;35(1):12–15. doi:10.5830/CVJA-2022-067.
29. Diederich T, Burdorf A, Pozehl B, Bowman S, Ferguson K, Holder K, Alonso W, Stoller D, Lundgren S. The role of a multidisciplinary heart failure clinic in optimization of guideline-directed medical therapy: HF-optimize. Heart Lung. 2023;57:95–101. doi:10.1016/j.hrtlng.2022.08.010.
30. Tan SS, Hisham SA, Bin Abdul Malek AM, Lik CP, Lau GSK, Bin Abdul Ghapar AK. Impact of multidisciplinary heart failure clinic on guideline-directed medical therapy and clinical outcomes. Can J Hosp Pharm. 2024;77(1):e3364. doi:10.4212/cjhp.3364.
31. Zavaleta-Monestel E, Arguedas-Chacón S, Quirós-Romero A, Chaverri-Fernández JM, Serrano-Arias B, Díaz-Madriz JP, García-Montero J, Speranza-Sanchez MO. Optimizing heart failure management: a review of the clinical pharmacist integration to the multidisciplinary health care team. Int J Heart Fail. 2023;6(1):1–10. doi:10.36628/ijhf.2023.0022.
32. Patil T, Ali S, Kaur A, Akridge M, Eppes D, Paarlberg J, Parashar A, Jarmukli N. Impact of pharmacist-led heart failure clinic on optimization of guideline-directed medical therapy (PHARM-HF). J Cardiovasc Transl Res. 2022;15(6):1424–1435. doi:10.1007/s12265-022-10262-9.
33. Fonarow GC, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride ML, Inge PJ, Mehra MR, O’Connor CM, Reynolds D, Walsh MN, Yancy CW. Improving evidence-based care for heart failure in outpatient cardiology practices. Circulation. 2010;122(6):585–596. doi:10.1161/CIRCULATIONAHA.109.934471.
34. Crespo-Leiro MG, Anker SD, Maggioni AP, Coats AJ, Filippatos G, Ruschitzka F, Ferrari R, Piepoli MF, Delgado Jimenez JF, Metra M, Fonseca C, Hradec J, Amir O, Logeart D, Dahlström U, Merkely B, Drozdz J, Goncalvesova E, Hassanein M, Chioncel O, Lainscak M, Seferovic PM, Tousoulis D, Kavoliuniene A, Fruhwald F, Fazlibegovic E, Temizhan A, Gatzov P, Erglis A, Laroche C, Mebazaa A. European Society of Cardiology Heart Failure Long-Term Registry (ESC-HF-LT): 1-year follow-up outcomes and differences across regions. Eur J Heart Fail. 2016;18(6):613–625. doi:10.1002/ejhf.566.
35. Rastogi T, Duarte K, Huttin O, Roubille F, Girerd N. The prescription pattern of heart failure medications in reduced, mildly reduced, and preserved ejection fractions. J Clin Med. 2022;12(1):99. doi:10.3390/jcm12010099.
36. Wongsalap Y, Poolpun D, Keawhai K, Kitpluem N, Pansiri P, Malaimat S, Senthong V, Kengkla K. Pharmacotherapy treatment patterns at hospital discharge and clinical outcomes among patients with heart failure with reduced ejection fraction. Chronic Dis Transl Med. 2023;9(2):154–163. doi:10.1002/cdt3.59.
37. McMurray JJV, Packer M, Desai AS, Gong J, Lefkowitz MP, Rizkala AR, Rouleau JL, Shi VC, Solomon SD, Swedberg K, Zile MR. Angiotensin–NEPRILYSIN inhibition versus enalapril in heart failure. N Engl J Med. 2014;371(11):993–1004. doi:10.1056/NEJMoa1409077.
38. Velazquez EJ, Morrow DA, DeVore AD, Duffy CI, Ambrosy AP, McCague K, Rocha R, Braunwald E. Angiotensin–NEPRILYSIN inhibition in acute decompensated heart failure. N Engl J Med. 2019;380(6):539–548. doi:10.1056/NEJMoa1812851.
39. Wachter R, Senni M, Belohlavek J, Straburzynska-Migaj E, Witte KK, Kobalava Z, Fonseca C, Goncalvesova E, Cavusoglu Y, Fernandez A, Chaaban S, Bøhmer E, Pouleur AC, Mueller C, Tribouilloy C, Lonn E, Buraiki JA, Gniot J, Mozheiko M, Lelonek M, Noè A, Schwende H, Bao W, Butylin D, Pascual-Figal D. Initiation of sacubitril/Valsartan in haemodynamically stabilised heart failure patients in hospital or early after discharge: Primary results of the Randomised Transition Study. Eur J Heart Fail. 2019;21(8):998–1007. doi:10.1002/ejhf.1498.
40. Jarjour M, Henri C, de Denus S, Fortier A, Bouabdallaoui N, Nigam A, O’Meara E, Ahnadi C, White M, Garceau P, Racine N, Parent MC, Liszkowski M, Giraldeau G, Rouleau JL, Ducharme A. Care gaps in adherence to heart failure guidelines: Clinical inertia or physiological limitations? JACC Heart Fail. 2020;8(9):725–738. doi:10.1016/j.jchf.2020.04.019.
41. Swat SA, Helmkamp LJ, Tietbohl C, Thompson JS, Fitzgerald M, McIlvennan CK, Harger G, Ho PM, Ahmad FS, Ahmad T, Buttrick P, Allen LA. Clinical inertia among outpatients with heart failure: application of treatment nonintensification taxonomy to EPICHF Trial. JACC Heart Fail. 2023;11(11):1579–1591. doi:10.1016/j.jchf.2023.06.022.
42. Malgie J, Wilde MI, Clephas PRD, Emans ME, Koudstaal S, Schaap J, Mosterd A, van Ramshorst J, Wardeh AJ, van Wijk S, van den Heuvel M, Wierda E, Borleffs CJW, Saraber C, Beeres SLMA, van Kimmenade R, Jansen Klomp W, Denham R, da Fonseca CA, Klip IT, Manintveld OC, van der Boon RMA, van Ofwegen CEE, Yilmaz A, Pisters R, Linssen GCM, Faber N, van Heerebeek L, van de Swaluw JEC, Bouhuijzen LJ, Post MC, Kuijper AFM, Wu KW, van Beek EA, Hesselink T, Kleijn L, Kurvers MJM, Tio RA, Langerveld J, van Dalen BM, van Eck JWM, Handoko ML, Hermans WRM, Koornstra-Wortel HJJ, Szymanski MK, Rooker D, Tandjung K, Eijsbouts SCM, Asselbergs FW, van der Meer P, Brunner-La Rocca HP, de Boer RA, Brugts JJ. Contemporary guideline-directed medical therapy in de novo, chronic, and worsening heart failure patients: First data from the TITRATE-HF study. Eur J Heart Fail. 2024;26(7):1549–1560. doi:10.1002/ejhf.3267.
43. Duangsong J, Samansaplert P, Khamkong Y, Jenghua K. Use of potentially inappropriate medications for heart failure according to the three sets of heart failure-specific criteria in Thai older patients with heart failure. J Geriatr Cardiol. 2022;19(7):498–510. doi:10.11909/j.issn.1671-5411.2022.07.001.
44. El Hadidi S, Vaughan C, Kerins D, Byrne S, Darweesh E, Bermingham M. Guideline-led prescribing to ambulatory heart failure patients in a cardiology outpatient service. Int J Clin Pharm. 2021;43(4):1082–1089. doi:10.1007/s11096-020-01220-z.
45. Arfè A, Scotti L, Varas-Lorenzo C, Nicotra F, Zambon A, Kollhorst B, Schink T, Garbe E, Herings R, Straatman H, Schade R, Villa M, Lucchi S, Valkhoff V, Romio S, Thiessard F, Schuemie M, Pariente A, Sturkenboom M, Corrao G. Non-steroidal anti-inflammatory drugs and risk of heart failure in four European countries: Nested case-control study. BMJ. 2016;354:i4857. doi:10.1136/bmj.i4857.
46. Page J, Henry D. Consumption of NSAIDs and the development of congestive heart failure in elderly patients: an underrecognized public health problem. Arch Intern Med. 2000;160(6):777–784. doi:10.1001/archinte.160.6.777.
47. Gislason GH, Rasmussen JN, Abildstrom SZ, Schramm TK, Hansen ML, Fosbøl EL, Sørensen R, Folke F, Buch P, Gadsbøll N, Rasmussen S, Poulsen HE, Køber L, Madsen M, Torp-Pedersen C. Increased mortality and cardiovascular morbidity associated with use of nonsteroidal anti-inflammatory drugs in chronic heart failure. Arch Intern Med. 2009;169(2):141–149. doi:10.1001/archinternmed.2008.525.
48. Sunaga T, Yokoyama A, Nakamura S, Miyamoto N, Watanabe S, Tsujiuchi M, Nagumo S, Nogi A, Maezawa H, Mizukami T, Ebato M, Suzuki H, Nakamura A, Watanabe T, Sasaki T. Association of potentially inappropriate medications with all-cause mortality in elderly acute decompensated heart failure patients: importance of nonsteroidal anti-inflammatory drug prescription. Cardiol Res. 2020;11(4):239–246. doi:10.14740/cr1078.
49. Goyal P, Kneifati-Hayek J, Archambault A, Mehta K, Levitan EB, Chen L, Diaz I, Hollenberg J, Hanlon JT, Lachs MS, Maurer MS, Safford MM. Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization. JACC Heart Fail. 2020;8(1):25–34. doi:10.1016/j.jchf.2019.08.007.
50. Jaber D, Vargas F, Nguyen L, Ringel J, Zarzuela K, Musse M, Kwak MJ, Levitan EB, Maurer MS, Lachs MS, Safford MM, Goyal P. Prescriptions for potentially inappropriate medications from the Beers criteria among older adults hospitalized for heart failure. J Card Fail. 2022;28(6):906–915. doi:10.1016/j.cardfail.2021.11.014.
2. National Heart Association of Malaysia. Clinical practice guidelines: Management of heart failure. 5th ed. Kuala Lumpur, Malaysia: National Heart Association of Malaysia; 2023.
3. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Piepoli MF, Price S, Rosano GMC, Ruschitzka F, Skibelund AK; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599–3726. doi:10.1093/eurheartj/ehab368.
4. Balakumaran K, Patil A, Marsh S, Ingrassia J, Kuo CL, Jacoby DL, Arora S, Soucier R. Evaluation of a guideline-directed medical therapy titration program in patients with heart failure with reduced ejection fraction. Int J Cardiol Heart Vasc. 2019;22:1–5. doi:10.1016/j.ijcha.2018.10.003.
5. Seo WW, Park JJ, Park HA, Cho HJ, Lee HY, Kim KH, Yoo BS, Kang SM, Baek SH, Jeon ES, Kim JJ, Cho MC, Chae SC, Oh BH, Choi DJ. Guideline-directed medical therapy in elderly patients with heart failure with reduced ejection fraction: A cohort study. BMJ Open. 2020;10(2). doi:10.1136/bmjopen-2019-030514.
6. Bassi NS, Ziaeian B, Yancy CW, Fonarow GC. Association of optimal implementation of sodium-glucose cotransporter 2 inhibitor therapy with outcome for patients with heart failure. JAMA Cardiol. 2020;5(8):948. doi:10.1001/jamacardio.2020.0898.
7. Vaduganathan M, Claggett BL, Jhund PS, Cunningham JW, Ferreira JP, Zannad F, Packer M, Fonarow GC, McMurray JJV, Solomon SD. Estimating lifetime benefits of comprehensive disease-modifying pharmacological therapies in patients with heart failure with reduced ejection fraction: A comparative analysis of three randomised controlled trials. Lancet. 2020;396(10244):121–128. doi:10.1016/S0140-6736(20)30748-0.
8. Komajda M, Anker SD, Cowie MR, Filippatos GS, Mengelle B, Ponikowski P, Tavazzi L; QUALIFY Investigators. Physicians’ adherence to guideline-recommended medications in heart failure with reduced ejection fraction: Data from the QUALIFY global survey. Eur J Heart Fail. 2016;18(5):514–522. doi:10.1002/ejhf.510.
9. Greene SJ, Butler J, Albert NM, DeVore AD, Sharma PP, Duffy CI, Hill CL, McCague K, Mi X, Patterson JH, Spertus JA, Thomas L, Williams FB, Hernandez AF, Fonarow GC. Medical therapy for heart failure with reduced ejection fraction: The CHAMPS registry. J Am Coll Cardiol. 2018;72(4):351–366. doi:10.1016/j.jacc.2018.04.070.
10. Teng TK, Tromp J, Tay WT, Anand I, Ouwerkerk W, Chopra V, Wander GS, Yap JJ, MacDonald MR, Xu CF, Chia YM, Shimizu W; ASIAN-HF Investigators; Richards AM, Voors AA, Lam CSP. Prescribing patterns of evidence-based heart failure pharmacotherapy and outcomes in the ASIAN-HF registry: A cohort study. Lancet Glob Health. 2018;6(9). doi:10.1016/S2214-109X(18)30306-1.
11. Shahid I, Khan MS, Fonarow GC, Butler J, Greene SJ. Bridging gaps and optimizing implementation of guideline-directed medical therapy for heart failure. Prog Cardiovasc Dis. 2024;82:61–69. doi:10.1016/j.pcad.2024.01.008.
12. Mohd Ghazi A, Teoh CK, Abdul Rahim AA. Patient profiles and outcomes in patients hospitalized for heart failure: A 10-year history of the Malaysian population. ESC Heart Fail. 2022;9(4):2664–2675. doi:10.1002/ehf2.13992.
13. Bermingham M, Ryder M, Travers B, Edwards N, Lalor L, Kelly D, Gallagher J, O’Hanlon R, McDonald K, Ledwidge M. The St Vincent’s potentially inappropriate medicines study: Development of a disease-specific consensus list and its evaluation in ambulatory heart failure care. Eur J Heart Fail. 2014;16(8):915–922. doi:10.1002/ejhf.132.
14. Ling HS, Chung BK, Chua PF, Gan KX, Ho WL, Ong EYL, Kueh CHS, Chin YP, Fong AYY. Acute decompensated heart failure in a non-cardiology tertiary referral centre, Sarawak General Hospital (SGH-HF). BMC Cardiovasc Disord. 2020;20(1):511. doi:10.1186/s12872-020-01793-7.
15. Raja Shariff RE, Kasim S, Borhan MK, Yusoff MR. Acute heart failure – The ‘real’ Malaysian experience: An observational study from a single non-cardiac centre. Proc Singapore Healthc. 2020;30(3):1–7. doi:10.1177/2010105820978664.
16. Zainal Abidin HA, Isa MR, Mohd Arshad MK, Ibrahima ZO, Ibrahima KS, Ismaila JR, Chuaa N, Najme Khira R, Lima CW, Abd Rahmana E, Kasim S. Guideline adherence to prescription in heart failure population in North Kuala Lumpur region. Int J Cardiol. 2017;249(15):s38. doi:https://doi.org/10.1016/j.ijcard.2017.09.135.
17. Shariff RE, Koh HB, Sabian IS, Quah WJ, Ong SH, Sulong MA, Jaafar J, Devi ST, Chan JAW, Abdul Rahim AA, Teoh CK, Mohd Ghazi A. The first Malaysian multidisciplinary team heart failure clinic: A tertiary cardiac centre experience. J Asian Pacific Soc Cardiol. 2023;2:e09. doi:https://doi.org/10.15420/japsc.2022.38.
18. Wan Ahmad WA, Abdul Ghapar AK, Zainal Abidin HA, Karthikesan D, Ross NT, S K Abdul Kader MA, Loch A, Mahendran K, Ramli AW, Ong TK, Mohd Amin NH, Lee CY, Che Hassan HH, Zainal Abidin SK, Liew HB, Ho WS, Mohd Ghazi A. Characteristics of patients admitted with heart failure: Insights from the first Malaysian Heart Failure Registry. ESC Heart Fail. 2024;11(2):727–736. doi:10.1002/ehf2.14608.
19. Lee SE, Lee HY, Cho HJ, Choe WS, Kim H, Choi JO, Jeon ES, Kim MS, Kim JJ, Hwang KK, Chae SC, Baek SH, Kang SM, Choi DJ, Yoo BS, Kim KH, Park HY, Cho MC, Oh BH. Clinical characteristics and outcome of acute heart failure in Korea: Results from the Korean Acute Heart Failure Registry (KorAHF). Korean Circ J. 2017;47(3):341–353. doi:10.4070/kcj.2016.0419.
20. Zhang Y, Gao C, Greene SJ, Greenberg BH, Butler J, Yu J, Zheng Z, Ma G, Wang L, Yang P, Ji X, Xu D, Wang J, Zhang Y, Liu Y, Zhao Y, Qi H, Zhai M, Feng J, Huang Y, Zhou Q, Zhang J. Clinical performance and quality measures for heart failure management in China: the China-Heart Failure registry study. ESC Heart Fail. 2023;10(1):342–352. doi:10.1002/ehf2.14184.
21. Tsuchihashi-Makaya M, Hamaguchi S, Kinugawa S, Yokota T, Goto D, Yokoshiki H, Kato N, Takeshita A, Tsutsui H; JCARE-CARD Investigators. Characteristics and outcomes of hospitalized patients with heart failure and reduced vs preserved ejection fraction. Circ J. 2009;73(10):1893–1900. doi:10.1253/circj.cj-09-0254.
22. Wang CC, Chang HY, Yin WH, Wu YW, Chu PH, Wu CC, Hsu CH, Wen MS, Voon WC, Lin WS, Huang JL, Chen SM, Yang NI, Chang HC, Chang KC, Sung SH, Shyu KG, Lin JL, Mar GY, Chan KC, Kuo JY, Wang JH, Chen ZC, Tseng WK, Cherng WJ. TSOC-HFrEF Registry: A registry of hospitalized patients with decompensated systolic heart failure. Acta Cardiol Sin. 2016;32(4):400–411. doi:10.6515/acs20160704a.
23. Tavazzi L, Senni M, Metra M, Gorini M, Cacciatore G, Chinaglia A, Di Lenarda A, Mortara A, Oliva F, Maggioni AP; IN-HF Outcome Investigators. Multicenter prospective observational study on acute and chronic heart failure: one-year follow-up results of IN-HF outcome registry. Circ Heart Fail. 2013;6(3):473–481. doi:10.1161/CIRCHEARTFAILURE.112.000161.
24. Anis-Syakira J, Jawahir S, Abu Bakar NS, Mohd Noh SN, Jamalul-Lail NI, Hamidi N, Sararaks S. Factors affecting the use of private outpatient services among the adult population in Malaysia. Int J Environ Res Public Health. 2022;19(20):13663. doi:10.3390/ijerph192013663.
25. National Health and Morbidity Survey (NHMS) 2023: Non-communicable diseases and healthcare demand - Key findings. Shah Alam, Malaysia: Institute for Public Health; 2024.
26. Powell-Wiley TM, Poirier P, Burke LE, Després JP, Gordon-Larsen P, Lavie CJ, Lear SA, Ndumele CE, Neeland IJ, Sanders P, St-Onge MP. Obesity and cardiovascular disease: A scientific statement from the American Heart Association. Circulation. 2021;143(21):e984–e1010. doi:10.1161/CIR.0000000000000973.
27. Bragazzi NL, Zhong W, Shu J, Abu Much A, Lotan D, Grupper A, Younis A, Dai H. Burden of heart failure and underlying causes in 195 countries and territories from 1990 to 2017. Eur J Prev Cardiol. 2021;28(15):1682–1690. doi:10.1093/eurjpc/zwaa147.
28. AlHabeeb W, Alayoubi F, Hayajneh A, Ullah A, Elshaer F. A strategy to improve adherence to guideline-directed medical therapy and the role of the multidisciplinary team in a heart-failure programme. Cardiovasc J Afr. 2024;35(1):12–15. doi:10.5830/CVJA-2022-067.
29. Diederich T, Burdorf A, Pozehl B, Bowman S, Ferguson K, Holder K, Alonso W, Stoller D, Lundgren S. The role of a multidisciplinary heart failure clinic in optimization of guideline-directed medical therapy: HF-optimize. Heart Lung. 2023;57:95–101. doi:10.1016/j.hrtlng.2022.08.010.
30. Tan SS, Hisham SA, Bin Abdul Malek AM, Lik CP, Lau GSK, Bin Abdul Ghapar AK. Impact of multidisciplinary heart failure clinic on guideline-directed medical therapy and clinical outcomes. Can J Hosp Pharm. 2024;77(1):e3364. doi:10.4212/cjhp.3364.
31. Zavaleta-Monestel E, Arguedas-Chacón S, Quirós-Romero A, Chaverri-Fernández JM, Serrano-Arias B, Díaz-Madriz JP, García-Montero J, Speranza-Sanchez MO. Optimizing heart failure management: a review of the clinical pharmacist integration to the multidisciplinary health care team. Int J Heart Fail. 2023;6(1):1–10. doi:10.36628/ijhf.2023.0022.
32. Patil T, Ali S, Kaur A, Akridge M, Eppes D, Paarlberg J, Parashar A, Jarmukli N. Impact of pharmacist-led heart failure clinic on optimization of guideline-directed medical therapy (PHARM-HF). J Cardiovasc Transl Res. 2022;15(6):1424–1435. doi:10.1007/s12265-022-10262-9.
33. Fonarow GC, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride ML, Inge PJ, Mehra MR, O’Connor CM, Reynolds D, Walsh MN, Yancy CW. Improving evidence-based care for heart failure in outpatient cardiology practices. Circulation. 2010;122(6):585–596. doi:10.1161/CIRCULATIONAHA.109.934471.
34. Crespo-Leiro MG, Anker SD, Maggioni AP, Coats AJ, Filippatos G, Ruschitzka F, Ferrari R, Piepoli MF, Delgado Jimenez JF, Metra M, Fonseca C, Hradec J, Amir O, Logeart D, Dahlström U, Merkely B, Drozdz J, Goncalvesova E, Hassanein M, Chioncel O, Lainscak M, Seferovic PM, Tousoulis D, Kavoliuniene A, Fruhwald F, Fazlibegovic E, Temizhan A, Gatzov P, Erglis A, Laroche C, Mebazaa A. European Society of Cardiology Heart Failure Long-Term Registry (ESC-HF-LT): 1-year follow-up outcomes and differences across regions. Eur J Heart Fail. 2016;18(6):613–625. doi:10.1002/ejhf.566.
35. Rastogi T, Duarte K, Huttin O, Roubille F, Girerd N. The prescription pattern of heart failure medications in reduced, mildly reduced, and preserved ejection fractions. J Clin Med. 2022;12(1):99. doi:10.3390/jcm12010099.
36. Wongsalap Y, Poolpun D, Keawhai K, Kitpluem N, Pansiri P, Malaimat S, Senthong V, Kengkla K. Pharmacotherapy treatment patterns at hospital discharge and clinical outcomes among patients with heart failure with reduced ejection fraction. Chronic Dis Transl Med. 2023;9(2):154–163. doi:10.1002/cdt3.59.
37. McMurray JJV, Packer M, Desai AS, Gong J, Lefkowitz MP, Rizkala AR, Rouleau JL, Shi VC, Solomon SD, Swedberg K, Zile MR. Angiotensin–NEPRILYSIN inhibition versus enalapril in heart failure. N Engl J Med. 2014;371(11):993–1004. doi:10.1056/NEJMoa1409077.
38. Velazquez EJ, Morrow DA, DeVore AD, Duffy CI, Ambrosy AP, McCague K, Rocha R, Braunwald E. Angiotensin–NEPRILYSIN inhibition in acute decompensated heart failure. N Engl J Med. 2019;380(6):539–548. doi:10.1056/NEJMoa1812851.
39. Wachter R, Senni M, Belohlavek J, Straburzynska-Migaj E, Witte KK, Kobalava Z, Fonseca C, Goncalvesova E, Cavusoglu Y, Fernandez A, Chaaban S, Bøhmer E, Pouleur AC, Mueller C, Tribouilloy C, Lonn E, Buraiki JA, Gniot J, Mozheiko M, Lelonek M, Noè A, Schwende H, Bao W, Butylin D, Pascual-Figal D. Initiation of sacubitril/Valsartan in haemodynamically stabilised heart failure patients in hospital or early after discharge: Primary results of the Randomised Transition Study. Eur J Heart Fail. 2019;21(8):998–1007. doi:10.1002/ejhf.1498.
40. Jarjour M, Henri C, de Denus S, Fortier A, Bouabdallaoui N, Nigam A, O’Meara E, Ahnadi C, White M, Garceau P, Racine N, Parent MC, Liszkowski M, Giraldeau G, Rouleau JL, Ducharme A. Care gaps in adherence to heart failure guidelines: Clinical inertia or physiological limitations? JACC Heart Fail. 2020;8(9):725–738. doi:10.1016/j.jchf.2020.04.019.
41. Swat SA, Helmkamp LJ, Tietbohl C, Thompson JS, Fitzgerald M, McIlvennan CK, Harger G, Ho PM, Ahmad FS, Ahmad T, Buttrick P, Allen LA. Clinical inertia among outpatients with heart failure: application of treatment nonintensification taxonomy to EPICHF Trial. JACC Heart Fail. 2023;11(11):1579–1591. doi:10.1016/j.jchf.2023.06.022.
42. Malgie J, Wilde MI, Clephas PRD, Emans ME, Koudstaal S, Schaap J, Mosterd A, van Ramshorst J, Wardeh AJ, van Wijk S, van den Heuvel M, Wierda E, Borleffs CJW, Saraber C, Beeres SLMA, van Kimmenade R, Jansen Klomp W, Denham R, da Fonseca CA, Klip IT, Manintveld OC, van der Boon RMA, van Ofwegen CEE, Yilmaz A, Pisters R, Linssen GCM, Faber N, van Heerebeek L, van de Swaluw JEC, Bouhuijzen LJ, Post MC, Kuijper AFM, Wu KW, van Beek EA, Hesselink T, Kleijn L, Kurvers MJM, Tio RA, Langerveld J, van Dalen BM, van Eck JWM, Handoko ML, Hermans WRM, Koornstra-Wortel HJJ, Szymanski MK, Rooker D, Tandjung K, Eijsbouts SCM, Asselbergs FW, van der Meer P, Brunner-La Rocca HP, de Boer RA, Brugts JJ. Contemporary guideline-directed medical therapy in de novo, chronic, and worsening heart failure patients: First data from the TITRATE-HF study. Eur J Heart Fail. 2024;26(7):1549–1560. doi:10.1002/ejhf.3267.
43. Duangsong J, Samansaplert P, Khamkong Y, Jenghua K. Use of potentially inappropriate medications for heart failure according to the three sets of heart failure-specific criteria in Thai older patients with heart failure. J Geriatr Cardiol. 2022;19(7):498–510. doi:10.11909/j.issn.1671-5411.2022.07.001.
44. El Hadidi S, Vaughan C, Kerins D, Byrne S, Darweesh E, Bermingham M. Guideline-led prescribing to ambulatory heart failure patients in a cardiology outpatient service. Int J Clin Pharm. 2021;43(4):1082–1089. doi:10.1007/s11096-020-01220-z.
45. Arfè A, Scotti L, Varas-Lorenzo C, Nicotra F, Zambon A, Kollhorst B, Schink T, Garbe E, Herings R, Straatman H, Schade R, Villa M, Lucchi S, Valkhoff V, Romio S, Thiessard F, Schuemie M, Pariente A, Sturkenboom M, Corrao G. Non-steroidal anti-inflammatory drugs and risk of heart failure in four European countries: Nested case-control study. BMJ. 2016;354:i4857. doi:10.1136/bmj.i4857.
46. Page J, Henry D. Consumption of NSAIDs and the development of congestive heart failure in elderly patients: an underrecognized public health problem. Arch Intern Med. 2000;160(6):777–784. doi:10.1001/archinte.160.6.777.
47. Gislason GH, Rasmussen JN, Abildstrom SZ, Schramm TK, Hansen ML, Fosbøl EL, Sørensen R, Folke F, Buch P, Gadsbøll N, Rasmussen S, Poulsen HE, Køber L, Madsen M, Torp-Pedersen C. Increased mortality and cardiovascular morbidity associated with use of nonsteroidal anti-inflammatory drugs in chronic heart failure. Arch Intern Med. 2009;169(2):141–149. doi:10.1001/archinternmed.2008.525.
48. Sunaga T, Yokoyama A, Nakamura S, Miyamoto N, Watanabe S, Tsujiuchi M, Nagumo S, Nogi A, Maezawa H, Mizukami T, Ebato M, Suzuki H, Nakamura A, Watanabe T, Sasaki T. Association of potentially inappropriate medications with all-cause mortality in elderly acute decompensated heart failure patients: importance of nonsteroidal anti-inflammatory drug prescription. Cardiol Res. 2020;11(4):239–246. doi:10.14740/cr1078.
49. Goyal P, Kneifati-Hayek J, Archambault A, Mehta K, Levitan EB, Chen L, Diaz I, Hollenberg J, Hanlon JT, Lachs MS, Maurer MS, Safford MM. Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization. JACC Heart Fail. 2020;8(1):25–34. doi:10.1016/j.jchf.2019.08.007.
50. Jaber D, Vargas F, Nguyen L, Ringel J, Zarzuela K, Musse M, Kwak MJ, Levitan EB, Maurer MS, Lachs MS, Safford MM, Goyal P. Prescriptions for potentially inappropriate medications from the Beers criteria among older adults hospitalized for heart failure. J Card Fail. 2022;28(6):906–915. doi:10.1016/j.cardfail.2021.11.014.
Article Sidebar
Published
Mar 12, 2026
Article Details
How to Cite
1.
Prescribing pattern, appropriateness, and factors influencing medication use in heart failure patients with reduced ejection fraction at a private tertiary hospital in Malaysia. Pharm Pract (Granada) [Internet]. 2026 Mar. 12 [cited 2026 Mar. 29];24(1):1-13. Available from: https://www.pharmacypractice.org/index.php/pp/article/view/3457
Section
Original Research
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
How to Cite
1.
Prescribing pattern, appropriateness, and factors influencing medication use in heart failure patients with reduced ejection fraction at a private tertiary hospital in Malaysia. Pharm Pract (Granada) [Internet]. 2026 Mar. 12 [cited 2026 Mar. 29];24(1):1-13. Available from: https://www.pharmacypractice.org/index.php/pp/article/view/3457