Guideline-directed Medical Therapy and Outcomes in Heart Failure with Reduced Ejection Fraction: A Multicentre Physician‑led Clinic Experience from Sarawak, Malaysia

Background: In Sarawak, Malaysia, non-cardiologist physician-led heart failure (HF) clinics were established to improve uptake of guideline-directed medical therapy (GDMT). The objective of this study was to describe GDMT implementation and clinical outcomes in patients with HF with reduced ejection fraction managed in physician-led clinics across Sarawak. Methods: A multicentre, retrospective cohort of adults (aged ≥18 years) with HF with reduced ejection fraction (left ventricular ejection fraction ≤40%) was followed in physician-led HF clinics at nine hospitals (1 January 2021 to 30 June 2023). Demographics, comorbidities, symptoms, left ventricular ejection fraction, N-terminal pro-B-type natriuretic peptide and GDMT use were collected at enrolment, 3 months (3M) and 6 months (6M). Outcomes were HF admission and all-cause mortality at 3M and 6M. Results: A total of 384 patients were enrolled (age 56.4 ± 13.7 years; 75.3% men). The comorbidity burden was high. Patients on three or more pillars of GDMT rose from 52% pre-clinic to 84% at 3–6M; use of four pillars increased from 12 to 49% at 6M. New York Heart Association class I increased from 26 to 60% by 6M. Among 150 patients with repeat echocardiography, left ventricular ejection fraction improved from 28.0 ± 7.6% to 39.7 ± 13.3%. N-terminal pro-B-type natriuretic peptide declined from 5,159 pg/ml (interquartile range 1,730–9,000) pre-clinic (n=19) to 611 (interquartile range 178–2,472) at 3M (n=30). By 3M, HF admission was 5.8% and mortality 4.2%; by 6M, HF admission was 7.7% and mortality was 10.4%. Conclusions: In a resource-constrained setting, a protocolised, physician-led clinic model achieved substantial GDMT uptake with improvements in symptoms alongside 3–6-month event rates comparable to other centres. These data support scaling pragmatic physician-led HF clinics to narrow evidence-to-practice gaps where specialist access is limited.