Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2021 Dec;23(12):1999-2007.
doi: 10.1002/ejhf.2378. Epub 2021 Dec 13.

Navigating between Scylla and Charybdis: challenges and strategies for implementing guideline-directed medical therapy in heart failure with reduced ejection fraction

Petar M Seferović  1   2 , Marija Polovina  1   3 , Christopher Adlbrecht  4 , Jan Bělohlávek  5 , Ovidiu Chioncel  6   7 , Eva Goncalvesová  8 , Ivan Milinković  1   3 , Avishay Grupper  9 , Róbert Halmosi  10 , Ginta Kamzola  11 , Konstantinos C Koskinas  12 , Yuri Lopatin  13 , Alexander Parkhomenko  14 , Pentti Põder  15 , Arsen D Ristić  1   3 , Gintarė Šakalytė  16 , Matias Trbušić  17 , Meiramgul Tundybayeva  18 , Bojan Vrtovec  19 , Yoto T Yotov  20   21 , Davor Miličić  17 , Piotr Ponikowski  22 , Marco Metra  23 , Giuseppe Rosano  24 , Andrew J S Coats  25
Affiliations
Free article
Review

Navigating between Scylla and Charybdis: challenges and strategies for implementing guideline-directed medical therapy in heart failure with reduced ejection fraction

Petar M Seferović et al. Eur J Heart Fail. 2021 Dec.
Free article

Abstract

Guideline-directed medical therapy (GDMT) has the potential to reduce the risks of mortality and hospitalisation in patients with heart failure (HF) with reduced ejection fraction (HFrEF). However, real-world data indicate that many patients with HFrEF do not receive optimised GDMT, which involves several different medications, many of which require up-titration to target doses. There are many challenges to implementing GDMT, the most important being patient-related factors (comorbidities, advanced age, frailty, cognitive impairment, poor adherence, low socioeconomic status), treatment-related factors (intolerance, side-effects) and healthcare-related factors that influence availability and accessibility of HF care. Accordingly, international disparities in resources for HF management and limited public reimbursement of GDMT, coupled with clinical inertia for treatment intensification combine to hinder efforts to provide GDMT. In this review paper, authors aim to provide solutions based on available evidence, practical experience, and expert consensus on how to utilise evolving strategies, novel medications, and patient profiling to allow the more comprehensive uptake of GDMT. Authors discuss professional education, motivation, and training, as well as patient empowerment for self-care as important tools to overcome clinical inertia and boost GDMT implementation. We provide evidence on how multidisciplinary care and institutional accreditation can be successfully used to increase prescription rates and adherence to GDMT. We consider the role of modern technologies in advancing professional and patient education and facilitating patient-provider communication. Finally, authors emphasise the role of novel drugs (especially sodium-glucose co-transporter 2 inhibitors), and a tailored approach to drug management as evolving strategies for the more successful implementation of GDMT.

Keywords: Guideline-directed medical therapy; Health education; Heart failure; Medication adherence; Optimal treatment; Quality of care; Sodium-glucose co-transporter 2 inhibitors.

PubMed Disclaimer

References

    1. Seferovic PM, Vardas P, Jankowska EA, Maggioni AP, Timmis A, Milinkovic I, et al. The Heart Failure Association atlas: heart failure epidemiology and management statistics 2019. Eur J Heart Fail. 2021;23(6):906-14.
    1. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599-726.
    1. Komajda M, Schöpe J, Wagenpfeil S, Tavazzi L, Böhm M, Ponikowski P, et al.; QUALIFY Investigators. Physicians' guideline adherence is associated with long-term heart failure mortality in outpatients with heart failure with reduced ejection fraction: the QUALIFY international registry. Eur J Heart Fail. 2019;21(7):921-9.
    1. Ouwerkerk W, Voors AA, Anker SD, Cleland JG, Dickstein K, Filippatos G, et al. Determinants and clinical outcome of uptitration of ACE-inhibitors and beta-blockers in patients with heart failure: a prospective European study. Eur Heart J. 2017;38(24):1883-90.
    1. Greene SJ, Fonarow GC, DeVore AD, Sharma PP, Vaduganathan M, Albert NM, et al. Titration of medical therapy for heart failure with reduced ejection fraction. J Am Coll Cardiol. 2019;73(19):2365-83.