Clinical profile and implementation of guideline-directed medical therapy in specialised heart failure clinics: insights from a multicentre registry

Background Specialised Heart Failure (HF) clinics are designed to improve the implementation of guideline-directed medical therapy (GDMT). However, contemporary multicentre real-world data on patient profiles and treatment optimisation in specialised outpatient settings remain limited. Purpose To characterise the clinical profile, laboratory biomarkers, and implementation of GDMT in outpatients with HF with reduced ejection fraction (HFrEF) followed in specialized clinics, with a specific focus on sex and age-related differences. Methods This prospective national multicentre registry included 1,099 outpatients with HFrEF (left ventricular ejection fraction ≤40%). Demographic characteristics, laboratory parameters, and GDMT use were analysed, including beta-blockers, mineralocorticoid receptor antagonists (MRA), sodium-glucose cotransporter-2 (SGLT-2) inhibitors, and renin-angiotensin system (RAS) inhibitors. Subgroup comparisons were performed according to sex and age (age ≥75 vs <75 years) using appropriate statistical tests. Results Median age was 64 years (IQR 56–72) and 27.8% were women. Median left ventricular ejection fraction was 29% (IQR 23–34). Ischaemic aetiology predominated (47.5%) and 17% had atrial fibrillation. Overall GDMT implementation was high: beta-blockers 96.2%, MRA 88.1%, and SGLT-2 inhibitors 81.4%. Regarding RAS inhibition, 44.2% received angiotensin receptor-neprilysin inhibitors, 25.3% angiotensin receptor blockers, and 21.9% angiotensin-converting enzyme inhibitors. Men showed a higher prevalence of ischaemic aetiology (56% vs 32%, p<0.001), higher creatinine (1.11 vs 0.89 mg/dL, p<0.001), and higher haemoglobin levels (14.9 vs 13.5 g/dL, p<0.001). Patients aged ≥75 years (18%) had more hypertension (78% vs 61%, p<0.001), atrial fibrillation (17% vs 10%, p=0.002), higher NT-proBNP (1,611 vs 1,065 pg/mL, p=0.003), higher creatinine (1.20 vs 1.01 mg/dL, p<0.001) and lower haemoglobin (13.7 vs 14.6 mg/dL, p<0.001). Quadruple foundational therapy was less frequent in older patients (51% vs 66%, p<0.001). Conclusions In a large national multicentre specialized HF clinic registry, GDMT implementation was high overall. Sex-related differences were mainly driven by aetiology and laboratory profile, without major disparities in therapeutic implementation. In contrast, older patients exhibited a higher comorbidity burden, worse biomarker profile, and significantly lower optimisation of quadruple therapy, highlighting a persistent therapeutic gap in this high-risk population.