Only 1 in 5 european HF centres "always" initiate all four GDMT pillars during hospitalisation despite near-universal IV iron and uptitration capacity

Background ESC guidelines recommend early, simultaneous initiation of the four foundational therapies for HFrEF (ACEi/ARB/ARNI, beta-blockers, MRAs, SGLT2 inhibitors). Trials supporting early post-discharge optimisation (e.g., STRONG-HF) highlight hospitalisation as a key opportunity to close the implementation gap. However, real-world consistency of in-hospital four-pillar initiation across European heart failure (HF) centres is uncertain. Purpose To quantify in-hospital initiation practices for GDMT pillars across European HF centres and contrast multi-drug initiation with adoption of other guideline-recommended interventions (iron deficiency screening/IV iron, rapid uptitration pathways). Methods Multinational, cross-sectional web-based survey of European HF centres (n=32; 14 countries). For six drug classes, respondents reported whether in-hospital initiation occurs “Always,” “If not contraindicated,” or “Sometimes.” “Four-pillar systematic initiation” was defined as reporting “Always” for all four foundational classes simultaneously (ACEi/ARB, beta-blocker, MRA, SGLT2 inhibitor), aligned with a protocol-default strategy (as tested in STRONG-HF). Four-pillar rates were compared within the same respondents against adoption of logistically complex guideline-recommended interventions (iron deficiency screening, IV iron therapy, rapid dose uptitration). The within-cohort contrast was assessed using McNemar’s exact test for paired nominal data. Results Only 7/32 centres (22%; 95% CI 9–40%) reported always initiating all four pillars during hospitalisation. Nearly half of centres (15/32) reported zero pillars initiated “Always,” revealing clear differences. Individual drug-class “Always” rates were: SGLT2 inhibitors 47% (15/32), beta-blockers 44% (14/32), MRAs 41% (13/32), ACEi/ARBs 38% (12/32), and ARNIs 22% (7/32). ARNIs showed the strongest inertia signal, with the highest “Sometimes” rate (34%, 11/32). Yet in the same respondents, IV iron therapy was universally available (32/32), iron deficiency screening was near-universal (31/32, 97%), and dose uptitration within 4–6 weeks was accessible at 94% of centres (30/32). The within-cohort gap between near-universal iron screening and four-pillar “Always” initiation (97% vs 22%) was statistically significant (p<10⁻⁶). Conclusion The bottleneck in European HF guideline implementation is the prescribing pathway. Centres that routinely deliver logistically complex IV iron therapy and rapid uptitration nevertheless fail to systematically initiate four oral therapies simultaneously. This implementation paradox (near-universal capacity but low systematic prescribing) reveals a process-level failure, not a resource gap. Closing this gap requires shifting initiation from individual clinical judgement to protocol-default: standardised order sets, discharge bundles, and prescribing performance feedback. ARNI initiation, as the most prominent bottleneck, warrants targeted intervention.