Utilization and dose optimization of beta-blockers in chronic heart failure therapy: a mixed-methods study.

Abstract

Background: Heart failure with reduced ejection fraction (HFrEF) represents a significant global health burden, affecting over 64 million individuals and resulting in substantial morbidity and mortality, particularly in resource-limited settings such as Ethiopia. The utilization of evidence-based beta-blockers (BBs) is paramount for enhancing clinical outcomes, yet their implementation and optimal dosing remain suboptimal. The study aimed to systematically assess the patterns of BB utilization and dosage optimization in HFrEF patients at the University of Gondar Comprehensive Specialized Hospital (UOG-CSH) while identifying critical determinants influencing their effective application.

Methods: This study employed a hospital-based, retrospective cohort design conducted from September 2018 to August 2023 G.C. The study included adult patients with HFrEF, aged ≥ 18 years, and an ejection fraction (EF) of ≤ 40%. A total sample size of 420 patients was determined using a systematic random sampling technique. Data were collected through structured questionnaires capturing socio-demographic details, clinical characteristics, and medication usage. Quantitative analysis was performed using SPSS version 27.0, applying binary logistic regression to identify factors associated with BB utilization and optimal dosing. The study rigorously followed the latest (2022) American Heart Association (AHA) and (2021) ESC guideline recommendations. Qualitative insights were gathered through semi-structured interviews with nine physicians and analyzed thematically to explore barriers and facilitators in BB management.

Results: Among the total of 420 patients with HFrEF 220 (52.4%) were on evidence-based BBs. Of those receiving evidence-based BBs, only 22 (10%) were taking the optimal dose. Factors significantly associated with BB use included age ≥ 65 years (AOR = 0.39, 95%CI: 0.23-0.67), ischemic heart disease (AOR = 3.78, 95%CI: 1.92-7.47), atrial fibrillation (AOR = 1.31, 95%CI: 1.11-6.55), hyperthyroidism (AOR = 5.78, 95%CI: 1.99-16.76), and duration of HF ≥ 3 years (AOR = 1.24, 95%CI: 1.01-3.07). For optimal dosing, valvular heart disease (AOR = 3.40, 95%CI: 1.15-10.04), number of comorbidities ≥ 2 (AOR = 7.27, 95%CI: 1.53-34.57), and duration of HF ≥ 3 years (AOR = 1.20, 95%CI: 1.38-3.71) were identified as significant predictors. Qualitative findings illuminated persistent barriers, including inadequate medication availability, suboptimal adherence to clinical practice guidelines, and patient compliance challenges.

Conclusion: The study highlights a significant therapeutic utilization gap in BBs, with only 10% of patients achieving optimal dosing. It recommends comprehensive training programs, strict adherence to guidelines, and improved medication accessibility.