Implementing the Cardio–kidney–metabolic (Ckm) Framework to Bridge the Therapeutic Gap in Heart Failure: Results From a Real–world Quality Improvement Project

Background The Cardio–Kidney–Metabolic (CKM) syndrome represents a clinical continuum where metabolic disorders, chronic kidney disease (CKD), and heart failure (HF) mutually exacerbate cardiovascular risk. Despite international guidelines recommending SGLT2 inhibitors (SGLT2i) as a cornerstone of treatment across the entire ejection fraction spectrum, a significant therapeutic gap persists in clinical practice. This study evaluates the impact of a targeted clinical intervention (“Gruppi di Miglioramento“) on therapeutic optimization in a high–risk cohort. Methods We analyzed a cohort of 151 patients (predominantly male, mean age 66 years) characterized by an HFpEF phenotype and comorbid CKD. A specific subgroup of 54 patients with documented therapeutic gaps was followed to assess the impact of a structured clinical audit and optimized pharmacological management on the prescription rates of disease–modifying therapies, with a focus on SGLT2i (Empagliflozin). Results Baseline analysis revealed a significant under–treatment in the HFpEF and CKD subgroups. Following the intervention, a dramatic increase in guideline–directed medical therapy (GDMT) was observed. Specifically, SGLT2i coverage increased from 14.7% to 85.3% in HFpEF patients (+70.6% ) and from 17.9% to 78.6% in CKD patients (+60.7% ). Significant improvements were also noted in patients with Type 2 Diabetes (from 15.4% to 69.2%). Overall, the project achieved a target therapeutic coverage ›85% for cardio–renal protection. Notably, patients with HFpEF reached the same intensity of care as those with HFrEF, ensuring therapeutic equity. Conclusions The implementation of a structured “Quality Improvement“ strategy effectively bridged the therapeutic gap in a complex CKM population. Targeted clinical interventions can rapidly optimize GDMT, ensuring that high–risk patients, particularly those with HFpEF and CKD, receive evidence–based treatments that simultaneously address cardiac, renal, and metabolic risks, thereby improving long–term prognostic outcomes.