Real-World Sacubitril/Valsartan Adoption and Post-Initiation Dose Reassessment and Titration in Heart Failure with Reduced Ejection Fraction: An Explanatory Sequential Mixed-Methods Study from Northern Saudi Arabia

Background/Objectives: Sacubitril/valsartan is a foundational therapy for heart failure with reduced ejection fraction (HFrEF), but real-world implementation extends beyond initiation to laboratory monitoring, follow-up, dose reassessment, and documentation of reasons for sub-target therapy. We evaluated this prescribing pathway in a regional Saudi heart-failure service.

Methods

This explanatory sequential mixed-methods study included 296 adults with HFrEF (left ventricular ejection fraction ≤40%) treated at a public referral hospital in Al-Qurayyat, Saudi Arabia, during 2020–2025. Quantitative analyses described active prescription, calendar-period variation, selected physiological caution features among non-users, initiation pathways, early monitoring, follow-up, escalation attempts, and dose status. Fifteen clinicians participated in semi-structured interviews analyzed using the Framework Method and the updated Consolidated Framework for Implementation Research; reporting followed COREQ.