{
  "abstract": "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. Results: Sacubitril/valsartan was active in 239/296 patients (80.7%). Among 57 non-users, 41 (71.9%) had at least one selected physiological caution feature. In 221 treated patients with ≥6 months of follow-up, 75.1% completed renal-function/potassium reassessment within 14 days, 67.9% had follow-up within six weeks, and 60.6% had an escalation attempt within 90 days. Current target-dose use was 16.7%, and 21.7% had reached target at any point. Of 116 patients currently receiving 24/26 mg twice daily, 91 had never been documented above the lowest dose, and 25 had previously reached a higher dose. Reasons for current lowest-dose therapy were clinical/physiological in 49, health-system/access-related in 5, patient preference/adherence-related in 4, and undocumented in 58. Qualitative findings emphasized monitoring continuity, explicit role ownership, appointment access, dose availability, and communication. Conclusions: High ARNI uptake did not ensure complete post-initiation dose reassessment and titration. The clearest measurable gap was uncertainty around current lowest-dose therapy when no reason or reassessment plan was documented; this represents a documentation/reassessment gap rather than proof of inappropriate care. Clinical audit should distinguish target-dose attainment, clinically limited sub-target dosing, active titration, return to a lower dose after prior escalation, access-related barriers, patient preference/adherence, and unresolved sub-target therapy.",
  "abstract_shown": true,
  "affiliations": [
    "Department of Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, Al-Ahliyya Amman University, Amman 19328, Jordan",
    "Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Saudi Arabia"
  ],
  "article_type": "research article",
  "arxiv": null,
  "author_total": 6,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "Reham Olayan Alonayzan"
    },
    {
      "affs": [
        0
      ],
      "name": "Alhareth Alsa’d",
      "orcid": "0009-0006-0395-7491"
    },
    {
      "affs": [
        0
      ],
      "name": "Zainab Zakaraya",
      "orcid": "0000-0003-3691-9759"
    },
    {
      "affs": [
        0
      ],
      "name": "Marwa A. Malouh"
    },
    {
      "affs": [
        0
      ],
      "name": "Anas Abed",
      "orcid": "0000-0003-2828-1011"
    },
    {
      "affs": [
        1
      ],
      "name": "Hayam A. AlRasheed",
      "orcid": "0009-0002-6186-848X"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/41hwx3586gf8f.bib",
  "cited_by": 0,
  "doi": "10.3390/jcm15208001",
  "fulltext_url": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13705730/?tool=EBI",
  "id": "41hwx3586gf8f",
  "issns": [
    "2077-0383"
  ],
  "landing_url": "https://www.mdpi.com/2077-0383/15/20/8001",
  "language": "eng",
  "licence": "CC-BY-4.0",
  "licence_label": "CC BY 4.0",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "openalex",
      "2705|Heart Failure Treatment and Management"
    ]
  ],
  "openalex": "W7222121655",
  "pdf_url": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13705730/pdf/?tool=EBI",
  "pmcid": "PMC13705730",
  "pmid": null,
  "published": "2026-10-01",
  "publisher": "MDPI AG",
  "ris": "https://research.draconitic.com/paper/41hwx3586gf8f.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T12:20:00Z",
      "native_id": "10.3390/jcm15208001",
      "source": "crossref",
      "url": "https://www.mdpi.com/2077-0383/15/20/8001"
    },
    {
      "first_seen": "2026-10-30T12:21:44Z",
      "native_id": "PMC:PMC13705730",
      "source": "europepmc",
      "url": "https://europepmc.org/article/PMC/PMC13705730"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "openalex:2705|Heart Failure Treatment and Management",
      "subfield": "cardiovascular"
    }
  ],
  "title": "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",
  "title_text": "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",
  "type": "peer-reviewed",
  "updated_at": "2026-10-30T12:21:44Z",
  "url": "https://research.draconitic.com/paper/41hwx3586gf8f",
  "venue": "Journal of Clinical Medicine",
  "versions": []
}