Practical Guidance on Implementation of Guideline‐Directed Medical Therapy in the Management of Heart Failure: Expert Opinion From the Middle East and Africa Region
Alferd Doku, Mohamed El‐Harari, Amr Badr, MD, Ahmed Bennis, Elijah Ogola, Waleed Alhabeeb, Magdy Abdelhamid, and Amam C. Mbakwem
Heart failure (HF) is a growing global health challenge, affecting over 56 million people worldwide and contributing significantly to cardiovascular mortality. While advances in treatment have improved outcomes in high-income countries, the burden of HF continues to rise in the Middle East and Africa (MEA) region, driven by demographic changes, increasing risk factors, and health system limitations.
The 2026 review by Doku et al. provides practical, region-specific guidance on implementing guideline-directed medical therapy (GDMT) for HF, aligning with the 2023 update of the European Society of Cardiology (ESC) guidelines. The paper highlights both the opportunities and the challenges of applying evidence-based treatment in real-world clinical settings across MEA countries.
The Rising Burden of Heart Failure in MEA
The prevalence of heart failure has steadily increased across the MEA region over recent decades. This trend is attributed to several factors, including:
• Aging populations
• High rates of hypertension, diabetes, obesity, and chronic kidney disease
• Urbanization and lifestyle changes
• Limited healthcare infrastructure in some African countries
Importantly, the causes of HF vary across regions. While coronary artery disease (CAD) remains dominant in Western countries, MEA populations show more diverse etiologies:
• Middle East: CAD, cardiomyopathy, and hypertension
• Sub-Saharan Africa: hypertensive heart disease, dilated cardiomyopathy, and HIV-related heart disease
These regional differences underscore the need for tailored diagnostic and therapeutic approaches.
Diagnosis and Classification of Heart Failure
Heart failure is a complex clinical syndrome characterized by symptoms such as shortness of breath, fatigue, and fluid retention, resulting from impaired cardiac function.
Diagnosis relies on:
• Clinical evaluation
• Imaging (especially echocardiography)
• Biomarkers such as natriuretic peptides (BNP, NT-proBNP), which are essential for confirming and assessing disease severity
HF is classified based on left ventricular ejection fraction (LVEF):
• HFrEF: ≤40%
• HFmrEF: 41–49%
• HFpEF: ≥50%
This classification guides treatment decisions and prognostic assessment.
Guideline-Directed Medical Therapy (GDMT): The Cornerstone of Treatment
GDMT represents a major breakthrough in HF management and includes four key drug classes:
1. Renin–angiotensin system inhibitors
2. Beta-blockers
3. Mineralocorticoid receptor antagonists (MRAs)
4. Sodium-glucose co-transporter-2 inhibitors (SGLT2i)
These therapies significantly reduce:
• Mortality
• Hospitalizations
• Disease progression
However, despite strong evidence, GDMT remains underutilized globally, particularly in MEA countries.
2023 ESC Update: Expanding the Role of SGLT2 Inhibitors
A key highlight of the updated ESC guidelines is the Class I recommendation for SGLT2 inhibitors in patients with:
• HF with mildly reduced EF (HFmrEF)
• HF with preserved EF (HFpEF)
Clinical trials such as EMPEROR-Preserved and DELIVER demonstrated that SGLT2 inhibitors:
• Reduce HF hospitalizations
• Improve clinical outcomes across a broad spectrum of patients
Additionally, these agents provide cardio-renal protection, making them particularly valuable for patients with comorbid diabetes and chronic kidney disease.
Challenges in Implementing GDMT in MEA
The implementation of GDMT faces multiple barriers across the region:
In African countries:
• Limited access and affordability of medications
• Weak healthcare infrastructure
• Lack of national HF guidelines
• Inadequate diagnostic resources at primary care level
In Middle Eastern countries:
• Therapeutic inertia among clinicians
• Poor patient adherence to medications
• Complexity of treatment regimens
Real-world studies show that only a fraction of patients receive optimal GDMT dosing, highlighting a significant gap between guidelines and practice.
Strategies to Improve Heart Failure Care
The paper outlines several practical solutions to enhance GDMT implementation:
1. Education and Awareness
• Train healthcare professionals, especially in primary care
• Increase patient awareness of HF and treatment benefits
2. Multidisciplinary Care
Effective HF management requires collaboration among:
• Cardiologists
• Primary care physicians
• Diabetologists
• Nephrologists
• Nurses and pharmacists
3. Early and Rapid Treatment Initiation
Rapid initiation of GDMT including SGLT2 inhibitors—can:
• Significantly reduce mortality and hospitalizations
• Improve quality of life
4. Health System Strengthening
• Develop national HF guidelines
• Improve access to diagnostic tools
• Expand insurance coverage for essential medications
5. Data Collection and Research
• Establish regional registries to assess disease burden
• Generate local evidence to inform policy decisions
The Role of Lifestyle and Patient Engagement
In addition to pharmacological therapy, lifestyle modifications remain essential:
• Maintaining a healthy weight
• Reducing salt and fluid intake
• Exercising regularly
• Quitting smoking and limiting alcohol
Equally important is shared decision-making, ensuring patients understand their treatment and remain adherent over the long term.
Conclusion
Heart failure poses a significant and growing challenge in the Middle East and Africa. While advances in guideline-directed medical therapy particularly the integration of SGLT2 inhibitors offer transformative potential, major gaps remain in implementation.
Addressing these gaps requires a multifaceted approach, including education, system-level reforms, multidisciplinary collaboration, and improved access to care. By adapting global guidelines to regional realities, healthcare systems can significantly improve outcomes and reduce the burden of heart failure across the MEA region.
Publication Link : https://www.ahajournals.org/doi/10.1161/JAHA.125.043650