Background: Heart failure with reduced ejection fraction remains a major cause of morbidity and mortality despite effective treatments. Guideline-directed medical therapy, commonly referred to as quadruple therapy, reduces mortality and hospitalisation; however, uptake and dose optimisation remain suboptimal across Asia, including Singapore. This study explores barriers and enablers influencing prescribing and titration practices in a multi-ethnic Asian setting. Methods: We conducted semi-structured interviews with 38 healthcare providers from seven public healthcare institutions in Singapore, including cardiologists, clinicians from relevant subspecialties, nurses, and pharmacists. The study was informed by the Cabana framework, and data were analysed using an inductive-deductive approach. Results: Guideline awareness was generally high, but confidence in initiating and up-titrating therapy varied. Attitudinal barriers included perceived gaps between clinical trial evidence and the realities of managing diverse patient populations, safety concerns in multi-morbid patients, clinical inertia, challenges related to professional boundaries, and limited confidence among junior staff. Nonetheless, guidelines were perceived as enablers, providing a shared framework that promotes standardised care. Prescribing behaviour was shaped by patient-related factors including financial constraints, limited health literacy, cultural preferences for traditional medicines, and treatment outcomes. Organisational barriers included limited access to specialist follow-up, rotating inpatient teams, formulary gaps in primary care, and fragmented medical records. Multidisciplinary nurse- or pharmacist-led titration clinics with specialist support were a key institutional enabler. Conclusions: To narrow the guideline-practice gap, targeted toolkits and specialist support are needed to address concerns and build staff confidence. A culture of reviewing quadruple therapy prescription at discharge and during follow-up should be supported. Prescribing patterns should be monitored and reflected in real-time, and patient adherence strengthened through dedicated heart failure nurses or case managers. Telehealth or primary care-based services, increased government support for healthcare information integration, and increased financial support for patients are necessary. Lay Summary Heart failure with reduced ejection fraction is a serious medical condition that can lead to frequent hospital admissions and premature death. Clinical guidelines strongly recommend the use of four classes of evidence-based medicines, commonly known as quadruple therapy, because they can significantly improve survival and reduce hospitalisation. Despite guideline endorsement, real-world uptake and dose optimisation of quadruple therapy remains suboptimal globally. Studies on implementation barriers in adhering to the guideline recommendations for quadruple therapy have focused mainly on physicians. This study provides one of the first multi-institutional qualitative accounts of barriers and enablers in prescribing quadruple therapy or guideline-directed medical therapy (GDMT) for heart failure patients in Singapore, exploring the views of all three frontline healthcare professional groups—doctors, nurses, and pharmacists. We found that the prescription of quadruple therapy was negatively influenced by a perceived gap between clinical trial evidence and the realities of managing diverse patient populations—particularly older and multimorbid patients—alongside interprofessional relationships and limited confidence among junior staff. Health care providers’ prescribing behaviour was shaped by patient-related factors, including financial constraints, limited health literacy, and cultural preferences for traditional medicines. Limited specialist follow-up, fragmented health records, and formulary gaps in primary care hinder implementation, while positive patient outcomes and multidisciplinary care models act as enablers in adhering to guideline recommendations. The study adds context-specific implementation insights by identifying individual, organisational, and system-level factors. Specialist-supported nurse- or pharmacist-led services, primary care-based medication titration, clearer task-sharing pathways, improved decision tools, and better health information integration may enhance guideline implementation.
The Fifth Universal Definition of Myocardial Infarction (UDMI) updates the classification to better reflect underlying pathophysiology, align with clinicalevaluation of patients, and incorporate objective diagnostic criteria. This classification recognizes that myocardial infarction occurs in three clinicalsettings. First, myocardial infarction can arise spontaneously due to an acute coronary pathology (primary myocardial infarction). While most presentations are due to atherothrombosis, alternative coronary pathologies can be identified using coronary imaging and functional testing. Second, myocardial infarction may result from another acute condition causing oxygen supply-demand imbalance (secondary myocardial infarction). Here, objective criteria are proposed to guide the use of cardiac and invasive or non-invasive coronary imaging, promoting consistent diagnosis and informing treatment. Third, myocardial infarction may occur as a complication of percutaneous or surgical cardiac procedures (procedure-related myocardial infarction). The diagnosis of procedure-related myocardial infarction does not rely on cardiac biomarker thresholds and is comparable for percutaneous and surgical procedures. In each of these three settings, guidance is provided on the interpretation of symptoms and signs of myocardial ischaemia, cardiac biomarkers, and imaging. Alignment of the classification of myocardial infarction with International Disease Classification (ICD)-11 codes, its distinction from myocardial injury, and implications for patients, public health, and research are discussed. It is anticipated that adoption of the classification in practice and research will ensure the diagnosis of myocardial infarction is meaningful for patients and clinicians with clear implications for care across healthcare settings.
Less than half of people with hypertension in Ethiopia are diagnosed, and only one-third of adults visiting primary care facilities have their blood pressure (BP) screened. We implemented a quality improvement (QI) initiative across six facilities in Ethiopia to increase facility-based BP screening. Process mapping identified barriers, and interventions were tested in iterative QI cycles: establishing BP screening desks at key service points, ensuring the availability of validated BP devices, training staff in accurate measurement, standardizing documentation, and reviewing screening indicators in performance meetings. Between April 2024 and February 2025, monthly BP screening of adults without a hypertension diagnosis increased from 41.0% of 13,707 eligible adults to 79.6% of 14,270 eligible adults. Monthly hypertension program enrollments rose from 40 in April 2024 to 125 in February 2025. Strengthening primary health care systems to systematically measure BP for all adults visiting health facilities can significantly improve hypertension detection and treatment.
This article details a correction to: Li X, Yu C, Lei L, Liu X, Chen Y, Wang Y, Qiu S, Xiu J. Association of Pre-PCI Blood Pressure and No-Reflow in Patients with Acute ST-Elevation Coronary Infarction. Global Heart. 2024;19(1):28. DOI: https://doi.org/10.5334/gh.1309 (1).
Introduction: In Africa, heart failure (HF) mortality is the highest in the world; approximately 50% of patients die within one year of HF hospitalization. Little is known about the quality of inpatient and post-discharge care and its association with patient outcomes. The purpose of this study is to describe HF outcomes for patients admitted in Northwestern Tanzania and evaluate associations between gaps in quality care and post-hospital survival. Methods: We conducted a retrospective chart review of all adult patients admitted with HF at Bugando Medical Centre in 2023. We abstracted data from the index hospitalization and subsequent encounters until August 31, 2025. Vital status was ascertained by telephone. We characterized post-discharge outcomes and adherence to guideline recommendations for HF care. Cox proportional hazards models assessed associations between gaps in quality measures and mortality. Results: Among 177 patients admitted with HF, 23 (13%) died during the index hospitalization. Of the 154 patients alive at discharge, 63 (40.9%) died within six months and 86 (56%) within a year. Among patients alive at discharge, 79% received indicated testing, 50% were on guideline-directed medical therapy (GDMT) at discharge, 68% attended the first post-discharge appointment, 53% received ongoing care three months post-discharge, and 39% were on GDMT three months post-discharge. Attending the first post-discharge visit (aHR 0.32 [95% CI: 0.17, 0.63]) and remaining in care three months after discharge (aHR 0.36 [95% CI: 0.16, 0.81]) were both independently associated with improved survival. GDMT use was low across outpatient visits (47%), with frequent medication changes and de-escalation over time. Conclusions: Mortality following HF admission in Northwestern Tanzania remains high. Factors associated with post-hospital mortality may include poor linkage to post-discharge care and low sustained care engagement. Implementation research is needed to develop strategies to improve post-discharge HF outcomes in East Africa, focusing on optimizing GDMT before discharge and improving early post-hospital linkage to care. Lay Summary Heart failure (HF) mortality in sub-Saharan Africa is the highest in the world, yet little is known about the quality of HF care provided during and after HF hospitalization and its relationship to post-hospital outcomes. This study seeks to understand the quality of care provided to patients admitted with HF in Northwestern Tanzania and its association with post-hospital outcomes. This study took place at Bugando Medical Centre, a large academic regional referral hospital in Mwanza, Tanzania that serves a catchment population of ~22 million people. Among 177 patients admitted with HF in 2023, there was a trend of high, early mortality following hospital discharge. Among the 154 patients who survived and were discharged, we found significant gaps in linkage to care after hospitalization, sustained retention in care, and utilization of guideline-directed medical therapy at discharge and in the outpatient setting. Linkage to care and retention in care were each independently associated with significant improvements in survival. There is a pressing need for future studies focused on understanding and addressing factors associated with post-hospital care engagement and utilization of guideline-directed medical therapy after HF hospitalization in East Africa.
