Proposed section structure
This topic is best organized around clinical relevance rather than a conventional drug-trial format. A logical structure is: Highlights; Clinical context and unmet need; Study design and methods; Key patient-derived themes; Clinical interpretation and implications for practice; Strengths and limitations; Conclusions; Funding and citation. This structure matches the qualitative design and keeps the focus on how the findings can inform routine heart failure care.
Highlights
Medication adherence in heart failure emerged as an ongoing process of fitting treatment into everyday life, not simply a question of patient willingness or motivation.
Four interdependent influences shaped adherence: practical medication-use challenges, psychosocial factors, health system and clinician interactions, and disease- or drug-related burdens such as symptoms, side effects, and diuretic timing.
Adherence was more reliable when regimens were simple, explicitly planned around daily routines, financially manageable, and supported by proactive follow-up, education, and multidisciplinary care.
The findings support routine assessment of adherence barriers in heart failure, including pharmacist involvement, psychosocial screening, and specific planning for diuretic use.
Clinical context and unmet need
Heart failure remains a major cause of morbidity, hospitalization, impaired quality of life, and premature death worldwide. Over the past decade, guideline-directed medical therapy has expanded substantially, with disease-modifying benefit now established for several core classes, including renin-angiotensin system inhibitors or angiotensin receptor-neprilysin inhibitors, evidence-based beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors. Yet the effectiveness seen in trials depends on sustained real-world medication use.
Medication adherence in heart failure is often discussed as if it were primarily a patient behavior problem. In practice, adherence is more complex. Patients may face polypharmacy, fluctuating symptoms, frequent dose changes, cognitive strain, financial barriers, and uncertainty about which drug does what. Diuretics create an especially distinctive challenge because they can improve congestion while simultaneously disrupting daily activity through urinary urgency, sleep disturbance, and concern about being away from home.
Guidelines emphasize education, self-care, and multidisciplinary management, but routine clinical workflows do not always capture how patients actually manage medication regimens in ordinary life. Quantitative studies can identify correlates of nonadherence, but they may miss the lived experience behind those numbers. This is where qualitative research is especially useful: it can clarify what patients mean when they say a regimen is difficult, burdensome, or unsustainable.
The current study by Gunnthorsdottir and colleagues addresses this gap by examining medication adherence from the patient perspective in heart failure. Its relevance is immediate for cardiologists, heart failure nurses, pharmacists, rehabilitation teams, and health systems trying to translate guideline-based prescribing into durable treatment implementation.
Study design and methods
This was a qualitative study conducted from May 2022 to November 2023. The investigators recruited 27 participants from the Icelandic Heart Failure Registry and a cardiac rehabilitation program. Data were generated through 4 focus groups and 12 in-depth interviews, allowing the researchers to capture both shared experiences and more individualized accounts.
The analysis used an inductive thematic approach, supported by field notes and multidisciplinary review. That methodological choice is appropriate when the aim is to derive concepts from participants’ narratives rather than test a pre-specified framework. The sample size is typical for qualitative inquiry seeking thematic saturation rather than statistical inference.
There were no interventions, comparators, or quantitative efficacy endpoints in the conventional sense. Instead, the principal output was a thematic map of factors influencing medication adherence in everyday life. This distinction matters: the value of the study lies in explanatory depth and clinical insight rather than effect size estimation.
Key findings
1. Practical aspects of medication use strongly shaped day-to-day adherence
The first major theme concerned the mechanics of taking medicines. Participants described the importance of stable routines, timing of doses, use of pill organizers or other adherence aids, difficulty with formulations, and the cumulative burden of polypharmacy. In heart failure, adherence is often not about remembering one tablet but about coordinating multiple medications with different schedules and effects.
This finding is clinically important because it reframes nonadherence as, in many cases, a systems design issue. If a regimen is hard to understand, hard to swallow, hard to fit around meals or work, or changes frequently without clear explanation, adherence predictably suffers. Patients were more likely to remain adherent when medications could be integrated into existing routines rather than imposed as a competing structure.
For clinicians, the practical lesson is straightforward: every additional complexity has a cost. Simplification should be treated as a therapeutic goal. This includes once-daily dosing where feasible, synchronization of refill dates, minimizing unnecessary duplication, and explicit discussion of how each drug will be taken in the context of the patient’s actual day.
2. Psychosocial influences were central, not peripheral
The second theme encompassed stress, mood, cognition, social support, and socioeconomic circumstances. These factors are sometimes labeled as “soft” influences, but the study suggests they are fundamental determinants of whether patients can sustain medication routines over time.
Stress and emotional strain may reduce attention to medications, especially when heart failure coexists with multimorbidity or social instability. Low mood can diminish motivation and executive functioning. Cognitive challenges, whether related to aging, comorbidity, or illness burden, complicate complex regimens. Social support can buffer these effects, while isolation can magnify them.
Socioeconomic context also mattered. Medication costs and the broader financial burden of chronic illness influenced patients’ ability to remain consistent. Importantly, the findings do not suggest that patients are indifferent to treatment. Rather, they show that real-life adherence competes with other urgent demands, including economic survival, caregiving responsibilities, and emotional exhaustion.
This has implications for routine care. Asking whether a patient is “taking medications as prescribed” is not enough. Adherence assessment should include screening for mood, cognitive difficulty, caregiver support, and affordability. Such barriers are often modifiable if identified early.
3. Interactions with the health care system could either support or undermine adherence
The third theme focused on education, follow-up, access, costs, patient-provider relationships, and home support. Participants valued clear explanations, continuity, and a sense that clinicians understood the practical consequences of treatment plans. When communication was fragmented or follow-up inconsistent, adherence became more fragile.
This is especially relevant in heart failure, where regimens are frequently titrated and where transitions of care are common after hospitalization. Patients may leave hospital with several medication changes but limited understanding of the rationale, expected benefits, or what adverse effects should trigger a call. Without structured follow-up, uncertainty can lead to missed doses, self-adjustment, or discontinuation.
The study’s emphasis on patient-provider relationships deserves attention. Trust and responsiveness appear to help patients sustain treatment even when regimens are burdensome. Conversely, if patients feel unheard or inadequately informed, adherence may deteriorate. This aligns with broader chronic disease literature showing that relational continuity and shared decision-making improve treatment engagement.
Pharmacist involvement is a particularly plausible implementation strategy. Pharmacists can reconcile medicines after discharge, identify duplication or interaction risks, counsel on timing and adverse effects, address formulation problems, and help manage refill logistics. In heart failure programs, pharmacists may be especially useful during uptitration and in patients with polypharmacy.
4. Disease- and medication-related factors introduced unique adherence barriers
The fourth theme included symptoms, physical limitations, diuretic burden, and side effects. These are highly heart failure-specific issues. A patient with fatigue, dyspnea, edema, frailty, or mobility impairment may find even basic medication management physically demanding. Moreover, medicines themselves can be experienced as burdensome, even when clinically necessary.
Diuretics stood out as a distinct challenge. Their benefits are tangible, but so are their inconveniences. Patients may skip or delay doses to avoid urinary frequency during travel, social events, work, or overnight hours. This is not irrational behavior; it reflects an attempt to preserve normalcy. The study therefore argues, implicitly and convincingly, for explicit diuretic planning as part of adherence support. Patients need individualized guidance on timing, anticipated effects, and what to do when routine circumstances change.
Side effects also influenced persistence. In heart failure care, clinicians often focus appropriately on prognostic benefit, but patients live with immediate sensations. Dizziness, hypotension, urinary issues, or other adverse effects may have a larger day-to-day impact than future risk reduction. Unless clinicians ask directly and normalize these conversations, patients may stop medication silently.
Clinical interpretation
The study’s core message is that medication adherence in heart failure is dynamic, contextual, and relational. That is a useful corrective to models that frame nonadherence primarily as patient noncompliance. Patients are often trying to make treatment workable within the limits of their bodies, households, finances, and health systems.
Several practical implications follow.
First, regimen simplification should be prioritized. Medication review should explicitly ask which drugs are hardest to remember, hardest to tolerate, hardest to afford, or hardest to fit into daily life. Simplification is likely to produce greater real-world benefit than adding therapies that patients cannot sustain.
Second, diuretic management requires special attention. Clinicians should discuss timing, daily schedules, access to bathrooms, sleep disruption, travel, and social functioning. Written plans may help, especially when symptoms fluctuate.
Third, adherence assessment should be multidimensional. Beyond asking about missed doses, clinicians should screen for depression or anxiety, cognitive strain, low health literacy, caregiver burden, transport difficulties, refill challenges, and out-of-pocket cost. These factors are often invisible unless specifically explored.
Fourth, follow-up should be coordinated and multidisciplinary. Heart failure nurses, pharmacists, rehabilitation clinicians, and primary care professionals all have complementary roles. A team-based model is especially valuable after hospital discharge and during therapy titration.
Finally, patient education must move beyond information transfer. The goal is not only for patients to know what each medicine is for, but also to have a workable strategy for taking it consistently under real-life conditions.
How these findings fit with current evidence and guidance
Contemporary heart failure guidelines from the American Heart Association, American College of Cardiology, and Heart Failure Society of America, as well as the European Society of Cardiology, emphasize self-care, multidisciplinary disease management, and optimization of guideline-directed medical therapy. However, they generally offer less granular guidance on how to identify and address the lived barriers to medication adherence. This study helps fill that operational gap.
The findings are also consistent with broader adherence research across chronic diseases showing that adherence improves when regimens are simplified, cost barriers are reduced, and patient education is coupled with behavioral and structural support. What is distinctive here is the disease-specific texture: polypharmacy, symptom burden, and especially the practical consequences of diuretic use.
For implementation science and quality improvement, the study suggests that adherence interventions in heart failure should be tailored rather than generic. A standard reminder system may help some patients but will not resolve affordability, adverse effects, weak follow-up, or a regimen that repeatedly clashes with daily routines.
Strengths and limitations
The study has several strengths. It addresses a clinically important but underexplored issue, uses both focus groups and individual interviews, and applies inductive thematic analysis with multidisciplinary review. The approach is well suited to understanding complexity and generating actionable hypotheses for practice redesign.
At the same time, several limitations should be considered. As with all qualitative studies, the findings are not statistically generalizable. The sample was modest and drawn from Icelandic clinical settings, including a registry and rehabilitation program, which may select for patients more connected to care than the broader heart failure population. Cultural, reimbursement, and health system factors may differ in other countries. The abstract does not provide granular demographic or clinical detail, so readers cannot fully assess representation by age, sex, heart failure phenotype, social vulnerability, or comorbidity burden.
Also, qualitative work captures perception and meaning rather than objectively measured adherence. That is not a flaw so much as a design feature, but it does mean the study complements rather than replaces quantitative adherence research using pharmacy refill data, electronic monitoring, or clinical outcomes.
Still, these limitations do not diminish the study’s practical contribution. In fact, they highlight the next step: development and testing of heart failure-specific adherence assessment tools and targeted interventions grounded in patient experience.
Implications for practice and research
Clinicians can begin applying these findings now. A brief structured medication adherence conversation in heart failure visits could include: Which medicines are hardest to take? When do side effects interfere with daily life? Do diuretics disrupt sleep, work, or leaving home? Are cost or refill timing barriers present? Who helps at home with medications? Has stress, mood, or forgetfulness made routines harder?
Health systems might incorporate pharmacist-led medication review, post-discharge follow-up calls, and simple tools for documenting adherence barriers within the electronic health record. Cardiac rehabilitation programs may also be valuable venues for adherence support because they combine education, symptom monitoring, and repeated patient contact.
Future research should test whether interventions built on these themes improve measurable adherence and clinical outcomes. Priorities include tailored diuretic counseling, co-designed adherence assessment tools, integration of social needs screening into heart failure clinics, and evaluation of multidisciplinary models that include pharmacists and nurses. It will also be important to examine whether adherence barriers differ by sex, frailty status, cognitive impairment, socioeconomic vulnerability, and heart failure phenotype.
Conclusion
This qualitative study provides a clinically useful reframing of medication adherence in heart failure. Patients do not experience adherence as a simple matter of motivation. They experience it as the ongoing work of fitting complex treatment into a life shaped by symptoms, side effects, costs, routines, emotions, relationships, and health system structures.
The practical message is clear: improve the fit between treatment and everyday life, and adherence is more likely to follow. For heart failure programs, that means simplifying regimens, planning explicitly for diuretics, screening for psychosocial and financial barriers, and providing coordinated multidisciplinary follow-up. These are not peripheral adjustments. They are central to realizing the benefit of guideline-directed medical therapy in the real world.
Funding and trial registration
No funding information or ClinicalTrials.gov registration number is provided in the abstract. As a qualitative interview and focus group study, trial registration may not be applicable.
Citation and selected references
Gunnthorsdottir I, Gunnarsdottir AI, Andersen K, Svansdottir E, Thrainsdottir IS, Forsyth P, Ingimarsdottir IJ, Almarsdottir AB. Exploring Medication Adherence in Heart Failure From a Patient Perspective: A Qualitative Study. Circulation. Heart Failure. 2026-05-10:e014133. PMID: 42108747. URL: https://pubmed.ncbi.nlm.nih.gov/42108747/
Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. Circulation. 2022;145:e895-e1032.
McDonagh TA, Metra M, Adamo M, et al. 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. 2023;44:3627-3639.
Ruppar TM, Cooper PS, Mehr DR, Delgado JM, Dunbar-Jacob JM. Medication adherence interventions improve heart failure mortality and readmission rates: systematic review and meta-analysis of controlled trials. Journal of the American Heart Association. 2016;5:e002606.
Nieuwlaat R, Wilczynski N, Navarro T, et al. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews. 2014;11:CD000011.
