Several possible reasons:

Fear of increasing a dose if there are concerns that the patient is non-adherent. For example, if you are not convinced that the patient is regularly taking medication, then you worry that an increase in the dose may cause hypotension or bradycardia. 

Lack of knowledge about the benefits of full titration. Some physicians and advanced practice clincians appear to believe that the BB and angiotenin blockers are for treatment of hypertension and not for neurohormonal blockade in heart failure.

You're right. The problem concerns both the doctor and the patient.

In my opinion the higher the symptomatology of the patient, the higher the compliance.

Sergei, if you are treating patients with decompensated heart failure, then there can't be  target doses (according to guidelines) for beta-blockers and ACE inhibitors. These medications should be started with very low doses and titrated upward, with an attempt to use doses to reduce the risk of worsening contractile function or a drop in systemic pressure.

There is a BIG diference between patients included in RCT with "real world patients"! Highly selected ( 1 of 10! ALL of them suffered form CHF!!), tough control : clinical, lab test ...

Has been treated patients with CHF for years trough the ambulantory service, and  vitnised good outcomes of them even wit smaller dosis - survival period is almost the same! Look at the survey - compare dosees of the drugs ant survival time!

Dear Nikolay,

I completely agree that we should start with minimal doses according guidelines and titrated up to max recommended doses. It is not very often we are limited due to low HR or BP. In some patients with BP 90-100 mm I increase time between correction doses up to 3-4 weeks or more and increase dose one medications.

Dear Stjepan,

you are really believe that no differences between low and high doses of BB and iACE in patient with CHF?

Dear Sergey,

The main substance of my last message was that there are no maximal recommended doses. You should titrated up to maximum tolerated doses! These should serve as an orienting point.

Thank you.

The biggest benefit from beta blockers comes from HR control in addition to modulating down the hyperactive sympathetic tone.

If low BP limits the gradual up titration of Beta blockers and patient is in sinus rhythm with heart  rate above 60, then Ivabradine has a role in controlling Heart rate around 60 BMP.

For hyperactive RAAS  System , which also contributes to pathological remodelling , the art of management is to reduce loop diuretic dose to the minimal necessary for symptoms control to allow for up titration of Medications that have mortality benefits in HF, namely ACE I or ARBs, HF  Beta  Blockers and Mineralo-corticosteroid Antagonists like Spironactone.

I believe that the main goal of treatment with beta-blockers is not as much to reduce the heart rate, as to reduce the influence of catecholamines on the cells of the working myocardium and pacemaker. Increase in heart rate is necessary to maintain cardiac output at a sufficient level. In patients with HFrEF one should not working towards to reduce the heart rate to normal values, e.g., as in a healthy person, if HR is not abnormally high.

As for Ivabradine, it can be added if there are a number of conditions:

"Ivabradine should be considered to reduce the risk of HF hospitalization and cardiovascular death in symptomatic patients with LVEF ≤35%, in sinus rhythm and a resting heart rate ≥70 bpm despite treatment with an evidence-based dose of beta- blocker (or maximum tolerated dose below that),ACE-I (or ARB), and an MRA (or ARB)".

"Ivabradine should be considered to reduce the risk of HF hospitalization and cardiovascular death in symptomatic patients with LVEF ≤35%, in sinus rhythm and a resting heart rate ≥70 bpm who are unable to tolerate or have contra-indications for a beta-blocker. Patients should also receive an ACE-I (or ARB) and an MRA (or ARB)".

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure https://doi.org/10.1093/eurheartj/ehw128

Similar conditions are given in 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure https://www.ncbi.nlm.nih.gov/pubmed/27216111

OK. Good answer. If we talk about Ivabradin In my opinion this medications often prescribe under recommendations. Maybe due to pharma promotional or another reason.

If you have any data how often use ivabradin in different countries? For examples in France (birthplace of the drug), in Western Europe and Eastern Europe?

The prescription of beta blockers may be optimized clearly among stable heart failure patients. The slight deterioration in symptoms noticed when commencing beta blockers often prevents achievement of optimal doses as quickly as possible. 

Co-morbidities significantly affect prescription or up-titration of life saving medications

ESC guidelines implementation in primary care patients with heart failure: focus on uptitration of life saving medications M. Nikolaou, J. Parissis, A. Karavidas , M. Papakonstantinou , G. Filippatos, P. Vardas. Greece.  

Purpose: The aim of this study was to describe the doses of ACE-I/ARBs and BB with respect to the proposed doses of ESC and identify which are the comorbidities that influence drug prescription or up-titration in the primary care. Methods: Fifty centers of primary care were randomly selected, with respect to geographical criteria, to participate in the study. Each center recruited 10 consecutive HF patients, with a HF diagnosis at least six months prior to enrollement. Demographic characteristics, medical history, current treatment and dosage were collected. Results: Among 500 enrolled patients, the great majority received ACE-I or alternatively ARBs (94.6%) and BB (92.8%). Among patients on RAAS inhibitors, 42.28% received the target dose, while among patients on BB, only 19.61% escalated up to the target dose. History of hypertension seems to correlate well with ACE-I/ARB and BB up-titration (OR 2.5 and 1.9 respectively, p

About ivabradin...

It is essential to follow 3 rules: EF, HR and max dose of BB.

U.S. Food and Drug Administration has granted approval of ivabradine, an oral medication indicated to reduce the risk of hospitalization for worsening heart failure in patients with stable, symptomatic chronic heart failure with left ventricular ejection fraction ≤35%, who are in sinus rhythm with resting heart rate ≥70 beats per minute and either are on maximally tolerated doses of beta blockers or have a contraindication to beta blocker use.

Importance of ACE-Inhibitor and Beta-Blocker Dosing for Outcomes in Patients With Heart Failure

Patients with HFrEF who were treated with less than 50% of recommended dose of ACE-inhibitors/ARBs and beta-blockers seemed to have a greater risk of death and/or heart failure hospitalization compared with patients reaching ≥100%.

http://www.practiceupdate.com/content/importance-of-ace-inhibitor-and-beta-blocker-dosing-for-outcomes-in-patients-with-heart-failure/50949