College of Pharmacy, National university of science and technology, An Nasiriyah, iraq
*Corresponding Author Email: tarigacad@gmail.com
Optimising discharge prescribing for four-pillar guideline-directed medical therapy (GDMT) remains a critical therapeutic priority in heart failure with reduced ejection fraction (HFrEF). Data regarding current trends in inpatient prescribing is scarce in resource-limited settings. This study aimed to describe the incidence of complete four-pillar GDMT at discharge and to assess factors associated with incomplete prescribing among hospitalized patients with diagnosed HFrEF from five hospitals in Nasiriyah, Iraq. This study was a retrospective cross-sectional multicenter analysis of consecutive eligible hospital discharges from January 1, 2024, to December 31, 2025, involving patients from five public hospitals in Nasiriyah City, Thi-Qar Governorate, southern Iraq. Adults diagnosed with echocardiographically-confirmed HFrEF (left ventricular ejection fraction ≤40%) were included if a discharge prescription was available for examination. The principal outcome was the comprehensive four-pillar guideline-directed medical therapy (GDMT) at discharge, characterized by the prescription of at least one agent from each of the following categories: angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or angiotensin receptor-neprilysin inhibitor; evidence-based beta-blocker; mineralocorticoid receptor antagonist; and sodium-glucose cotransporter-2 inhibitor (SGLT2i). Prespecified multivariable logistic regression models were employed to assess factors correlated with the administration of complete guideline-directed medical therapy (GDMT) at discharge, adjusting for predetermined variables known to predict incomplete four-pillar prescribing, including enrolment centre, estimated glomerular filtration rate (eGFR), prescriber speciality group, type 2 diabetes mellitus, NYHA class, and serum potassium levels. Two hundred ten discharges were evaluated, leading to the inclusion of 160 eligible patients in the final analyses. The average age was 62.4 years (SD 10.9), with 102 (63.7%) of 160 patients being male, and the median left ventricular ejection fraction was 30.5% (IQR 26.1–34.6). At discharge, complete four-pillar GDMT was recommended to 52 patients (32.5%, 95% CI 25.3–40.4). At discharge, prescription rates for the four guideline-mandated pillars were as follows: 64.4% received an ACE inhibitor/ARB/ARNI, 71.2% received an evidence-based beta-blocker, 58.1% received a mineralocorticoid receptor antagonist, and 39.4% received an SGLT2 inhibitor. Receipt of comprehensive four-pillar GDMT was greater among patients prescribed by a cardiologist than by a non-cardiologist in the centre-adjusted multivariable model (adjusted OR 2.88, 95% CI 1.27–8.41; p=0.028). Elevated eGFR and the existence of type 2 diabetes mellitus correlated with increased likelihood of receiving complete GDMT, but elevated serum potassium levels and NYHA class were linked to decreased likelihood of complete GDMT at discharge. The most significant disparity in prescribing practices between specialists and non-specialists was noted for SGLT2 inhibitors (51.9% vs to 26.6%). In a cohort of hospitalized patients with proven HFrEF from five hospitals in Nasiriyah City, Iraq, less than one-third were discharged on comprehensive four-pillar GDMT. Prescribing by cardiologists was associated with a higher likelihood of completing guideline-directed medical therapy (GDMT) at discharge, with the most significant deficiency in four-pillar prescribing observed with SGLT2 inhibitors. These findings underscore a significant deficiency in the discharge-level application of modern HFrEF medication within this regional hospital system and guide future evaluations of optimization options, including pharmacist-assisted discharge review.
Keywords: Heart failure with reduced ejection fraction, guideline-directed medical therapy, hospital discharge, prescribing patterns, sodium-glucose cotransporter-2 inhibitors, prescriber specialty, Iraq, retrospective cross-sectional study
How to cite this article: Osman T, Muhammed A, Jabbar E, Muslim Z, Hassan R, Sabah S, Hatem J, Hantosh A, Moneim Z, Alawi Z. Discharge prescribing of four-pillar guideline-directed medical therapy in hospitalized patients with HFrEF: a multicentre retrospective cross-sectional study from Nasiriyah, Iraq. Int J Drug Deliv Technol. 2026;16(16s): 703-722. DOI: 10.25258/ijddt.16.16s.76
Source of support: Nil.
Conflict of interest: None