Therapeutic Management of Heart Failure with Reduced Ejection Fraction in Morocco: Adherence to International Guidelines and Comparison with Global Registries

Abstract

Background: Heart failure with reduced ejection fraction (HFrEF) is a leading cause of cardiovascular mortality and morbidity worldwide. Optimized pharmacological therapy — comprising the four pillars of neurohormonal blockade (ACE inhibitors/ARBs, beta-blockers, MRA, SGLT2i) — has substantially reduced mortality and morbidity. The primary therapeutic goal in HFrEF is to improve survival, reduce hospitalizations, and enhance quality of life through guideline-directed medical therapy (GDMT). Adherence to guidelines varies internationally, particularly in low- and middle-income countries. Objectives: To evaluate prescribing patterns and adherence to ESC guidelines for HFrEF management at the Avicenne Military Hospital, Marrakech, and compare with international benchmarks. Methods: Retrospective observational study of 173 HFrEF patients (LVEF <40%) hospitalized between December 2021 and December 2023. Inclusion criteria: adults aged ≥18 years with echocardiographically confirmed HFrEF. Exclusion criteria: patients with incomplete medical records or those transferred before completion of diagnostic workup. Diagnosis was confirmed by transthoracic echocardiography, clinical assessment, and BNP/NT-proBNP levels. Comorbidities including hypertension, diabetes mellitus, atrial fibrillation, chronic kidney disease, and ischemic heart disease were systematically recorded. Prescription rates for each drug class and interventional procedures were extracted. Results: Beta-blockers were prescribed in 87%, mineralocorticoid receptor antagonists (MRA) in 78%, ACE inhibitors in 74%, SGLT2 inhibitors in 33%, and sacubitril/valsartan in 8%. Percutaneous coronary intervention (PCI) was performed in 33%, coronary bypass surgery in 11%. Device therapies (CRT, ICD) were markedly underutilized (2 and 1 patients, respectively). Conclusion: Pharmacological management at this center aligns broadly with ESC guidelines, with notably good beta-blocker and MRA uptake. However, SGLT2i and sacubitril/valsartan prescribing remains below guideline targets, and device therapy is markedly underutilized, reflecting resource constraints and access issues in the Moroccan context.