Adherence to 2021 ESC Heart Failure Guidelines Differed Across Practices

A recent survey conducted by the European Society of Cardiology (ESC) revealed significant differences in the implementation of the 2021 heart failure guidelines across global health care settings, particularly in the use of guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF).¹

Published in the European Journal of Heart Failure, the survey included responses from 457 cardiologists across 88 countries, with most being general cardiologists (54%), followed by heart failure specialists (19.4%), other cardiac specialists (18.9%), and noncardiac specialists (7.7%).²

Over half of the respondents (52.1%) used a combination of echocardiography and natriuretic peptides (NPs) for diagnosing HFrEF, while 33.2% relied primarily on echocardiography alone. Diagnostic approaches also varied by region, with Europe showing a higher utilization of NPs compared with other continents.

In terms of therapy, 91.2% of physicians indicated that angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor–neprilysin inhibitors (ARNi) were their first-line treatments, followed by β-blockers at 73.8%, mineralocorticoid receptor antagonists (MRAs) at 53.4%, and sodium-glucose cotransporter 2 (SGLT2) inhibitors at 48.1%. Additionally, 39.3% of physicians preferred using the combination treatment of ACEi/ARNi plus β-blockers and MRAs, while 33.3% preferred ACEi/ARNi plus β-blockers and SGLT2 inhibitors, and 22.2% preferred just ACEi/ARNi plus β-blockers. These rates suggest strong adherence to guideline recommendations but highlight that SGLT2 inhibitors, a key component of quadruple therapy, are still underused in nearly half of cases.

“SGLT2 inhibitors were still underused, despite the proven prognostic benefit in HF, but this medication gains trust and it was acknowledged as having a substantial favourable future impact on clinical outcomes,” the authors wrote.

The survey also highlighted challenges in diagnosing and managing common comorbidities associated with heart failure | Image credit: irissca – stock.adobe.com

There were also differences in how quickly GDMT was initiated and optimized. While only 8.3% of respondents reported completing GDMT optimization in less than a month, the majority (52%) estimated it took 1 to 3 months, and 31.8% said it took 3 to 6 months. Heart failure specialists were more likely than general cardiologists to implement a parallel rather than sequential approach to initiating therapy, which could accelerate the time to optimal treatment.

The results also exposed disparities in guideline adherence depending on the health care setting. Physicians in academic hospitals were more likely to follow the ESC guidelines closely, while nonacademic institutions reported longer time frames for GDMT initiation and lower adherence overall.

Interestingly, 61.6% of respondents stated that they used patient phenotyping, which tailors GDMT based on clinical characteristics. This approach was more common among heart failure specialists, indicating a more personalized treatment philosophy that aligns with the latest ESC recommendations. While most physicians used phenotyping “because it is reflective of the real clinical scenario,” according to the survey, 28.1% were not familiar with the concept of phenotyping, and 10.3% said they did not use it primarily due to a lack of safety evidence.

The survey also highlighted challenges in diagnosing and managing common comorbidities associated with heart failure. Screening for iron deficiency or anemia was routinely performed by 80.4% of respondents, while only 25.8% actively screened for sleep disorders such as sleep apnea in patients with HFrEF.

Despite the clear benefits of cardiac rehabilitation, only 4.7% of cardiologists prescribed it regularly, while 45.5% reserved it for severe cases, suggesting underutilization of this supportive therapy.

“Cardiac rehabilitation prescription is not a common practice among the participating physicians, and it is not perceived as part of the standard of care in HF, being prescribed by less than half of them,” the authors said. “The simplest explanations for the underutilization could be related to economic issues and the lack of designated on-site rehabilitation centres linked to HF departments.”

Despite these challenges, 53.1% of physicians—primarily general cardiologists—acknowledged the importance of the ESC guidelines as a whole in their daily practice, and 49.9% found the document highly useful for optimizing their care of patients with heart failure. These figures indicate that while there is room for improvement, many physicians are committed to integrating guideline-directed therapies into their practice.

“Data from this type of survey may contribute to the understanding of the diversity of care and may also contribute to standardizing HF care, crucial for minimizing practice variability and reducing disparities in patient outcomes,” the authors concluded.

References

1. McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) with the special contribution of the Heart Failure Association (HFA) of the ESC. Rev Esp Cardiol (Engl Ed). 2022;75(6):523. doi:10.1016/j.rec.2022.05.005
2. Christodorescu R, Geavlete O, Ferrini M, et al. Translating the 2021 ESC heart failure guideline recommendations in daily practice: results from a heart failure survey. A scientific statement of the ESC Council for Cardiology Practice and the Heart Failure Association of the ESC. Eur J Heart Fail. Published online September 24, 2024. doi:10.1002/ejhf.3444