{
  "abstract": "Objectives To describe prescription patterns, dosing and persistence of guideline-directed medical therapy (GDMT) among patients with heart failure with reduced ejection fraction in Singapore, and to identify factors associated with the use of quadruple therapy (ACE inhibitor (ACEi)/angiotensin II receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI), β-blocker, mineralocorticoid receptor antagonist (MRA) and sodium-glucose cotransporter-2 (SGLT2) inhibitor).Design Retrospective, observational cohort study.Setting Secondary and tertiary care settings across seven public hospitals in Singapore.Participants 3999 adults hospitalised from 2020 to 2022 with a first heart failure-related admission and left ventricular ejection fraction ≤40%. Patients with absolute contraindications to specific GDMT classes were excluded from eligibility calculations.Primary and secondary outcome measures Primary outcomes were the proportions of eligible patients prescribed each GDMT class and quadruple therapy at discharge. Secondary outcomes were 6-month prescription patterns, dose attainment and predictors of quadruple therapy use.Results Among eligible patients, 80%–99% met criteria for each GDMT drug class, yet only 29% received quadruple therapy at discharge in 2022. Prescription rates for ACEi/ARB/ARNI (67%), beta-blockers (89%), MRAs (40%), and SGLT2 inhibitors (46%) remained suboptimal despite high eligibility. At discharge, over 90% of patients on ACEi/ARB/ARNI and beta-blockers received ≤50% of target doses. By 6 months, prescription rates declined by 16% for ACEi/ARB/ARNI, 26% for beta-blockers and 7% for MRAs, while SGLT2 inhibitor use increased. Older age (OR 0.97, 95% CI 0.96 to 0.98) and chronic kidney disease stage 3a–4 (OR 0.65 to 0.04) were associated with lower odds of receiving quadruple therapy, while significant institutional variation was observed.Conclusions Despite high eligibility, uptake and optimisation of GDMT remain poor in Singapore, with substantial treatment gaps driven by underprescription, inadequate dosing and discontinuation. Interventions targeting clinician awareness, postdischarge support and institutional practice variation may improve adherence to guideline-recommended therapy.",
  "authors": [
    {
      "affiliations": [
        "Health Services Research & Population Health, Duke-NUS Medical School, Singapore",
        "National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore",
        "Australian Centre for Health Services Innovation (AusHSI), Queensland University of Technology, Brisbane, Queensland, Australia"
      ],
      "name": "Sameera Senanayake"
    },
    {
      "affiliations": [
        "Department of Cardiology, National Heart Centre Singapore, Singapore"
      ],
      "name": "Audry Shan Yin Lee"
    },
    {
      "affiliations": [
        "Health Services Research & Population Health, Duke-NUS Medical School, Singapore"
      ],
      "name": "Nicholas Graves"
    },
    {
      "affiliations": [
        "Health Services Research & Population Health, Duke-NUS Medical School, Singapore"
      ],
      "name": "Phoo Pyae Sone Win"
    },
    {
      "affiliations": [
        "National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore"
      ],
      "name": "Annie Lee"
    },
    {
      "affiliations": [
        "National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore"
      ],
      "name": "Yee How Lau"
    },
    {
      "affiliations": [
        "National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore",
        "Cardiovascular & Metabolic Disorders Program, Duke-NUS Medical School, Singapore",
        "Yong Loo Lin School of Medicine, National University of Singapore, Singapore",
        "The Hatter Cardiovascular Institute, University College London, London, UK",
        "Cardiovascular Disease National Collaborative Enterprise, Singapore"
      ],
      "name": "Derek J Hausenloy"
    },
    {
      "affiliations": [
        "Department of Cardiology, National Heart Centre Singapore, Singapore",
        "Duke-NUS Medical School, Singapore"
      ],
      "name": "Khung-Keong Yeo"
    },
    {
      "affiliations": [
        "Yong Loo Lin School of Medicine, National University of Singapore, Singapore",
        "Cardiovascular Disease National Collaborative Enterprise, Singapore",
        "Department of Cardiology, National University Heart Centre, Singapore"
      ],
      "name": "Mark Yan-Yee Chan"
    },
    {
      "affiliations": [
        "Yong Loo Lin School of Medicine, National University of Singapore, Singapore",
        "Department of Cardiology, National University Heart Centre, Singapore"
      ],
      "name": "Raymond Ching Chiew Wong"
    },
    {
      "affiliations": [
        "Department of Cardiology, Tan Tock Seng Hospital, Singapore"
      ],
      "name": "Seet Yoong Loh"
    },
    {
      "affiliations": [
        "Department of Cardiology, National Heart Centre Singapore, Singapore"
      ],
      "name": "Kheng Leng David Sim"
    },
    {
      "affiliations": [
        "Changi General Hospital, Singapore"
      ],
      "name": "Weien Chow"
    },
    {
      "affiliations": [
        "Ministry of Health Singapore, Singapore",
        "Saw Swee Hock School of Public Health, National University Singapore, Singapore"
      ],
      "name": "Kelvin Bryan Tan"
    },
    {
      "affiliations": [
        "Health Services Research & Population Health, Duke-NUS Medical School, Singapore",
        "National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore",
        "Australian Centre for Health Services Innovation (AusHSI), Queensland University of Technology, Brisbane, Queensland, Australia"
      ],
      "name": "Sanjeewa Kularatna"
    }
  ],
  "title": "Treatment gaps in guideline-directed medical therapy for HFrEF in Singapore: findings from a multicentre retrospective cohort study",
  "uid": "c41c2895-d9f6-57e2-b032-a4884019df50"
}