What does this research mean for the field?

Only 7.7% of patients with HFrEF received the maximal doses of guideline-directed medical therapy despite regular medication adherence. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

This study investigates why patients with HFrEF often do not receive the target doses of guideline-directed medical therapy.

February 6, 2026

Gaps between guidelines and everyday clinical practice in the treatment of heart failure patients with reduced ejection fraction (HFrEF): we still have much to learn

Key Result

Only 7.7% of 266 HFrEF patients achieved maximal doses of all four GDMT pillars, with clinical inertia and side effects as main barriers.

Key Points

This study investigates why patients with HFrEF often do not receive the target doses of guideline-directed medical therapy.
Conducted a registry-based study of patients with HFrEF hospitalized between September 2021 and September 2023.
Collected data on therapy adherence, doses, and reasons for not achieving target doses.
Obtained follow-up data through clinical visits or phone interviews.
Analyzed 266 patients with newly diagnosed HFrEF, with a mean age of 64 years.
Only 7.7% of patients received the maximum doses of all four pillars of guideline-directed therapy.
Primary reasons for not achieving maximum doses included lack of dosage increases, kidney function issues, low blood pressure, and clinical inertia.

Structured PICO

Population

266 patients with newly diagnosed HFrEF hospitalized at a single center between September 2021 and September 2023, mean age 64 years, 27.4% female.

Intervention

Guideline-directed medical therapy (GDMT) for HFrEF

Outcome

Reasons for not achieving target doses of guideline-directed medical therapy (GDMT)

This registry study highlights that clinical inertia and physiological barriers like low blood pressure and renal dysfunction severely limit the achievement of target GDMT doses in real-world HFrEF patients.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

Abstract Background Previous studies have shown that real-life patients with HFrEF (Heart Failure with Reduced Ejection Fraction) often fail to reach the target doses of disease-modifying treatments that demonstrate benefits in randomized controlled trials (RCTs), which form the basis of guideline recommendations. The reasons behind this appear to be multifactorial, leading to a gap between guideline recommendations and everyday clinical practice. Purpose This study aimed to investigate the main reasons why patients with HFrEF are not receiving the target doses of guideline-directed medical therapy (GDMT). Methods We conducted a registry-based study including patients with HFrEF hospitalized at our center between September 2021 and September 2023. Information was collected on therapy adherence, doses, and reasons for not achieving target doses. Follow-up data were obtained through clinical visits or phone interviews. Results This study analyzed 266 patients with newly diagnosed HFrEF, and GDMT was initiated according to the ESC (European Society of Cardiology) guidelines. The mean age of the patients was 64 years (IQR 16), and 27.4% were female. Only 7.7% of the patients were on the maximal doses of all four pillars of GDMT. Most patients regularly took their prescribed medication, and adherence did not vary significantly between different groups of medications. The primary reasons for not achieving maximum doses included lack of dosage increase attempts, issues with kidney function and potassium levels and low blood pressure Conclusion The greatest challenges in achieving guideline-directed medical therapy (GDMT) for HFrEF include clinical inertia, side effects, and patients' perceptions of the necessity of medication. Physicians may overestimate the quality of care they provide, contributing to clinical inertia. Other factors include time constraints during office visits, patient nonadherence, and reluctance to adjust therapy. Additionally, gaps in education, training, and organizational support are well-recognized causes of clinical inertia.

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