Implementation gaps in contemporary heart failure therapy: a two-country nationwide analysis

Background To assess implementation of contemporary guideline-directed medical therapy (GDMT) for heart failure (HF) across two nationwide public healthcare systems, including treatment persistence across care settings and uptake of sodium–glucose cotransporter-2 inhibitors (SGLT2i).Methods Data were obtained from the Patient, Prescribed Drug and Cause of Death registers in Norway and Sweden. Dose titration and discontinuation of newly initiated GDMT were evaluated in patients with an incident HF visit to outpatient or inpatient care between 1 January 2022 and 31 December 2022. Additionally, uptake of SGLT2i between 1 January 2020 and 31 December 2023, was assessed in patients with incident HF or prevalent HF.Results During 2022, across Norway and Sweden, 57 779 patients initiated GDMT for HF in outpatient care and 54 239 patients in inpatient care with similar characteristics across the two countries. More than 80% of patients treated with SGLT2i remained on the target dose during follow-up; compared with approximately 5% and 40% for angiotensin receptor blockers and angiotensin receptor-neprilysin inhibitors, respectively. Discontinuation rates were consistently higher with GDMT initiated in outpatient care than with that initiated in inpatient care. Uptake of SGLT2i increased rapidly among patients with incident HF, reaching approximately 45% in Norway (2022) and 55% in Sweden (2023) whereas uptake among patients with prevalent HF remained low (10–12%).Conclusions Implementation gaps in contemporary HF therapy persist. While uptake of SGLT2i increased rapidly following incident HF, utilisation among patients with established HF remained limited and treatment persistence was lower with GDMT initiated in outpatient care.