Physician perceptions, attitudes, and strategies towards implementing guideline-directed medical therapy in heart failure with reduced ejection fraction. A survey of the Heart Failure Association of the ESC and the ESC Council for Cardiology Practice

Gianluigi Savarese^#^{1

2}, Felix Lindberg^#¹, Ruxandra M Christodorescu³, Marc Ferrini⁴, Thomas Kumler^{5

6}, Konstantinos Toutoutzas⁷, Giuseppe Dattilo⁸, Antoni Bayes-Genis^{9

10}, Brenda Moura¹¹, Offer Amir¹², Mark C Petrie¹³, Petar Seferovic¹⁴, Ovidiu Chioncel^{15

16}, Marco Metra¹⁷, Andrew J S Coats¹⁸, Giuseppe M C Rosano^{19

20}

Affiliations

¹ Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
² Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden.
³ Department V Internal Medicine, University of Medicine and Pharmacy V. Babes Timisoara, Institute of Cardiology Research Center, Timișoara, Romania.
⁴ Department of Cardiology and Vascular Pathology, CH Saint Joseph and Saint Luc, Lyon, France.
⁵ Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark.
⁶ Steno Diabetes Center Copenhagen, Denmark.
⁷ First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, 'Hippokration' General Hospital of Athens, Athens, Greece.
⁸ Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.
⁹ Institut del Cor, Hospital Universitari Germans Trias I Pujol, Barcelona, Spain.
¹⁰ Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV; Departamento de Medicina, Universitat Autònoma de Barcelona), Barcelona, Spain.
¹¹ Armed Forces Hospital, Faculty of Medicine of the University of Porto, Porto, Portugal.
¹² Heart Institute, Hadassah Medical Center & Faculty of Medicine, Hebrew University, Jerusalem, Israel.
¹³ Institute of Cardiovascular and Medical Sciences, The University Court of the University of Glasgow, Glasgow, UK.
¹⁴ University Medical Center, Medical Faculty University of Belgrade, Serbian Academy of Sciences and Arts, Belgrade, Serbia.
¹⁵ Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania.
¹⁶ University of Medicine Carol Davila, Bucharest, Romania.
¹⁷ Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
¹⁸ Heart Research Institute, Sydney, Australia.
¹⁹ Cardiovascular Clinical Academic Group, St George's University Hospital, London, UK.
²⁰ Cardiology, IRCCS San Raffaele, Rome, Italy.

^# Contributed equally.

PMID: 38515385
DOI: 10.1002/ejhf.3214

Free article

Physician perceptions, attitudes, and strategies towards implementing guideline-directed medical therapy in heart failure with reduced ejection fraction. A survey of the Heart Failure Association of the ESC and the ESC Council for Cardiology Practice

Gianluigi Savarese et al. Eur J Heart Fail. 2024 Jun.

Free article

. 2024 Jun;26(6):1408-1418.

doi: 10.1002/ejhf.3214. Epub 2024 Mar 22.

Authors

Affiliations

¹ Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
² Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden.
³ Department V Internal Medicine, University of Medicine and Pharmacy V. Babes Timisoara, Institute of Cardiology Research Center, Timișoara, Romania.
⁴ Department of Cardiology and Vascular Pathology, CH Saint Joseph and Saint Luc, Lyon, France.
⁵ Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark.
⁶ Steno Diabetes Center Copenhagen, Denmark.
⁷ First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, 'Hippokration' General Hospital of Athens, Athens, Greece.
⁸ Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.
⁹ Institut del Cor, Hospital Universitari Germans Trias I Pujol, Barcelona, Spain.
¹⁰ Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV; Departamento de Medicina, Universitat Autònoma de Barcelona), Barcelona, Spain.
¹¹ Armed Forces Hospital, Faculty of Medicine of the University of Porto, Porto, Portugal.
¹² Heart Institute, Hadassah Medical Center & Faculty of Medicine, Hebrew University, Jerusalem, Israel.
¹³ Institute of Cardiovascular and Medical Sciences, The University Court of the University of Glasgow, Glasgow, UK.
¹⁴ University Medical Center, Medical Faculty University of Belgrade, Serbian Academy of Sciences and Arts, Belgrade, Serbia.
¹⁵ Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania.
¹⁶ University of Medicine Carol Davila, Bucharest, Romania.
¹⁷ Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
¹⁸ Heart Research Institute, Sydney, Australia.
¹⁹ Cardiovascular Clinical Academic Group, St George's University Hospital, London, UK.
²⁰ Cardiology, IRCCS San Raffaele, Rome, Italy.

^# Contributed equally.

PMID: 38515385
DOI: 10.1002/ejhf.3214

Abstract

Aims: Recent guidelines recommend four core drug classes (renin-angiotensin system inhibitor/angiotensin receptor-neprilysin inhibitor [RASi/ARNi], beta-blocker, mineralocorticoid receptor antagonist [MRA], and sodium-glucose cotransporter 2 inhibitor [SGLT2i]) for the pharmacological management of heart failure (HF) with reduced ejection fraction (HFrEF). We assessed physicians' perceived (i) comfort with implementing the recent HFrEF guideline recommendations; (ii) status of guideline-directed medical therapy (GDMT) implementation; (iii) use of different GDMT sequencing strategies; and (iv) barriers and strategies for achieving implementation.

Methods and results: A 26-question survey was disseminated via bulletin, e-mail and social channels directed to physicians with an interest in HF. Of 432 respondents representing 91 countries, 36% were female, 52% were aged <50 years, and 90% mainly practiced in cardiology (30% HF). Overall comfort with implementing quadruple therapy was high (87%). Only 12% estimated that >90% of patients with HFrEF without contraindications received quadruple therapy. The time required to initiate quadruple therapy was estimated at 1-2 weeks by 34% of respondents, 1 month by 36%, 3 months by 24%, and ≥6 months by 6%. The average respondent favoured traditional drug sequencing strategies (RASi/ARNi with/followed by beta-blocker, and then MRA with/followed by SGLT2i) over simultaneous initiation or SGLT2i-first sequences. The most frequently perceived clinical barriers to implementation were hypotension (70%), creatinine increase (47%), hyperkalaemia (45%) and patient adherence (42%).

Conclusions: Although comfort with implementing all four core drug classes in patients with HFrEF was high among physicians, a majority estimated implementation of GDMT in HFrEF to be low. We identified several important perceived clinical and non-clinical barriers that can be targeted to improve implementation.

Keywords: Guideline‐directed medical therapy; Heart failure with reduced ejection fraction; Treatment implementation.

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References

1. Tromp J, Ouwerkerk W, van Veldhuisen DJ, Hillege HL, Richards AM, van der Meer P, et al. A systematic review and network meta‐analysis of pharmacological treatment of heart failure with reduced ejection fraction. JACC Heart Fail 2022;10:73–84. https://doi.org/10.1016/j.jchf.2021.09.004
1. Turgeon RD, Barry AR, Hawkins NM, Ellis UM. Pharmacotherapy for heart failure with reduced ejection fraction and health‐related quality of life: A systematic review and meta‐analysis. Eur J Heart Fail 2021;23:578–589. https://doi.org/10.1002/ejhf.2141
1. Savarese G, Carrero JJ, Pitt B, Anker SD, Rosano GMC, Dahlström U, et al. Factors associated with underuse of mineralocorticoid receptor antagonists in heart failure with reduced ejection fraction: An analysis of 11 215 patients from the Swedish Heart Failure Registry. Eur J Heart Fail 2018;20:1326–1334. https://doi.org/10.1002/ejhf.1182
1. Greene SJ, Tan X, Yeh YC, Bernauer M, Zaidi O, Yang M, et al. Factors associated with non‐use and sub‐target dosing of medical therapy for heart failure with reduced ejection fraction. Heart Fail Rev 2022;27:741–753. https://doi.org/10.1007/s10741‐021‐10077‐x
1. Stolfo D, Sinagra G, Savarese G. Evidence‐based therapy in older patients with heart failure with reduced ejection fraction. Card Fail Rev 2022;8:e16. https://doi.org/10.15420/cfr.2021.34

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Physician perceptions, attitudes, and strategies towards implementing guideline-directed medical therapy in heart failure with reduced ejection fraction. A survey of the Heart Failure Association of the ESC and the ESC Council for Cardiology Practice

Affiliations

Physician perceptions, attitudes, and strategies towards implementing guideline-directed medical therapy in heart failure with reduced ejection fraction. A survey of the Heart Failure Association of the ESC and the ESC Council for Cardiology Practice

Authors

Affiliations

Abstract

References

MeSH terms

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LinkOut - more resources

Full Text Sources

Medical

Research Materials

Miscellaneous