Why do Clinicians not Prescribe Quadruple Medical Therapy for Heart Failure with Reduced Ejection Fraction?

This article refers to 'Guideline-directed medical therapy in severe heart failure with reduced ejection fraction: An analysis from the HELP-HF registry' by D. Tomasoni et al., published in this issue on pages 327-337.In 2018, the primary results of the CHAMP-HF registry were published showing that among eligible patients with heart failure with reduced ejection fraction (HFrEF) in US clinical practice, many did not receive guideline-directed medical therapy (GDMT). 1 The results were shocking to many: one in three eligible patients were not prescribed a beta-blocker, one in four eligible patients were not prescribed a renin-angiotensin system inhibitor (RASi), and two in three eligible patients were not prescribed a mineralocorticoid receptor antagonist (MRA). 1 Less than one in four were prescribed triple therapy and a mere 1% were prescribed triple therapy at the target dose. 1 However, aside from the specific findings themselves, what made the results of CHAMP-HF particularly discouraging was that there had been no meaningful progress in GDMT use since the last large outpatient US HFrEF registry nearly a decade earlier. 2 Likewise, even now multiple years since CHAMP-HF, numerous contemporary studies continue to show persistent gaps and stagnation in our quest to improve GDMT implementation, both in the US and Europe.[3][4][5] Furthermore, the same narrative of slow and variable adoption seen with older therapies has attached itself to newer therapies for HFrEF.In the Swedish HF registry from 2020 to 2022, only 37% of eligible patients with HFrEF were prescribed a sodium-glucose cotransporter 2 inhibitor (SGLT2i).4 Findings were even worse in a US registry analysis from 2021 to 2022 where only one in five eligible patients hospitalized for HFrEF were discharged on an SGLT2i, and <1 in 10 on quadruple medical therapy.3 While underuse of GDMT for HFrEF was perhaps once shocking, the reality is that with analysis after analysis confirming persistent gaps, many in the heart failure (HF) community may unfortunately become desensitized.To our knowledge, there is not The opinions expressed in this article are not necessarily those of the Editors of the European Journal of Heart Failure or of the European Society of Cardiology.