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Abstract Aims Optimal management of heart failure with reduced ejection fraction (HFrEF) includes titration of guideline‐directed medical therapy (GDMT) to the highest tolerated dose within the licensed range. During hospitalization, GDMT doses are often significantly altered, although it is unknown whether the cause of hospitalization influences this. Methods and results We recruited 711 people with stable HFrEF from specialist heart failure clinics and prospectively assessed events occurring during first unplanned hospitalization. Dose changes of ACE inhibitors or angiotensin receptor blockers (ACEi/ARB), beta‐blockers, mineralocorticoid receptor antagonists, and loop diuretics were recorded during 414 hospitalizations, categorized as due to decompensated heart failure, other cardiovascular causes, infection, or other non‐cardiovascular causes. Most hospitalizations resulted in no change to GDMT. ACEi/ARB dose was reduced in 21% of hospitalizations and was more common during non‐cardiovascular hospitalization (25.4% vs. 13.9%; P = 0.005). ACEi/ARB dose reduction was associated with older age and lower left ventricular ejection fraction at study recruitment, and poorer renal function, lower systolic blood pressure, higher serum potassium, and less frequent care from a cardiologist during admission. People experiencing ACEi/ARB reduction had worse age‐adjusted survival after discharge, without differences in heart failure re‐hospitalization. De‐escalation of beta‐blockers occurred in 8% of hospitalizations, most often due to other non‐cardiovascular causes; this was not associated with post‐discharge survival or re‐hospitalization with heart failure. Conclusions De‐escalation of HFrEF GDMT is more common during non‐cardiovascular hospitalization and for ACEi/ARB is associated with reduced survival. Post‐discharge care plans should include robust plans to consider re‐escalation of GDMT in these cases.

Abstract Introduction Missed appointments are a major health issue in the healthcare systems globally. They directly impact on the use of hospital resources, patient's health, and can lead to patient's dissatisfaction. This study was conducted to assess the reasons for missing a hospital appointment. Methods A survey was conducted with a randomly selected sample of patients who missed their outpatient appointment in Royal hospital, Sultanate of Oman, from March to April 2021 in six clinics. Patients were interviewed via telephone to answer a structured survey. In addition, a self‐administered survey was distributed to medical staff to explore their perspectives. Results Two hundred eighty patients and 52 medical staff participated in the study. Frequent patient‐reported reasons for missed appointment were transportation difficulties (11.4%), no longer needing (7.5%), or forgetting the appointment (6.8%); staff‐reported reasons were transportation (23.8%), no SMS received (16.9%), and forgetting the appointment (15.4%). Frequencies of reasons varied substantially between clinics. Family obligations were the main theme in obstetrics (odds ratio [OR] 9.48; 95% confidence interval [CI] 2.66‐33.78) and in diabetes clinic (OR 10.55; 95% CI 2.68‐38.58), where transportation issue was the main theme in Oncology clinic (OR 4.83; 95% CI 1.11‐21.02). The recommendations for improvement were mainly around improving the reminder system, the use of telephone reminders, and developing a flexible appointment scheduling system. Conclusion Knowing the reasons for missed appointment from patients and health professionals can help to develop effective interventions. The heterogeneity between clinics in reasons for missed appointment indicates for interventions tailored to clinic and frequent reasons.