Barriers and facilitators for the uptake of the national INOCA recommendation among Dutch cardiologists: A survey study

Q: What are the key findings of this study?

Among 134 Dutch cardiologists, 42% were unaware of or had not read the national INOCA guideline, with uptake driven by user expectations (89.7-98.7%) but hindered by lacking institutional policies (74.4%).

Q: What is the clinical evidence from this study?

Study design: Cross-Sectional. Population: Implementation of Ischaemia with Non-Obstructive Coronary Arteries (INOCA) national recommendation among cardiologists (n=134). Intervention: Dutch Society for Cardiologists (NVVC) national INOCA recommendation uptake and attitudinal determinants. Primary outcome: Determinants (facilitators and barriers) of NVVC INOCA recommendation implementation and factors associated with recommendation familiarity (B = 0.54 (perceived improvement in knowledge predicting familiarity), 95% CI 0.24-0.84, p=<0.05).

Q: What does this research mean for the field?

Uptake of the national INOCA recommendation among Dutch cardiologists is driven by positive individual professional commitment but hindered by organizational deficits, with 42% being unaware of or having not read the guideline despite treating INOCA patients. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To identify facilitators and barriers affecting the clinical implementation of the Dutch national recommendation for the diagnosis and treatment of ischaemia with non-obstructive coronary arteries (INOCA).

Irene Göttgens; Lianne C. G. Roelofs; Jojanneke Smeenk; Linda Modderkolk; Sabine Oertelt‐Prigione

doi:10.1016/j.ijcrp.2026.200718

October 8, 2026International Journal of Cardiology Cardiovascular Risk and PreventionOpen Access

Barriers and facilitators for the uptake of the national INOCA recommendation among Dutch cardiologists: A survey study

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Key result

Nearly ~42% of Dutch cardiologists report unfamiliarity with national INOCA guidelines, largely hindered by institutional barriers.

B = 0.54 (perceived improvement in knowledge predicting familiarity)
95% CI 0.24-0.84
P<0.05
n=134

Why the study?

Following the 2020 Dutch Society for Cardiologists national recommendation on the historically underrecognized condition of Ischaemia with Non-Obstructive Coronary Arteries (INOCA), the facilitators and barriers determining its clinical implementation among Dutch cardiologists needed to be identified.

What are the key barriers, facilitators, and attitudinal determinants associated with the familiarity and uptake of the national INOCA recommendation among Dutch cardiologists?

Key Points

To identify facilitators and barriers affecting the clinical implementation of the Dutch national recommendation for the diagnosis and treatment of ischaemia with non-obstructive coronary arteries (INOCA).
Nationwide cross-sectional online survey of Dutch cardiologists (N=134) incorporating the Measurement Instrument for Determinants of Innovation (MIDI) questionnaire.
Participants completed either a full questionnaire (n=78, 58%) if aware of the recommendation and treating INOCA, or a short version (n=56, 42%).
Determinants were evaluated using descriptive statistics, and multivariable linear regression assessed factors independently associated with recommendation familiarity.
Among respondents, 42% (n=56) had not read or were unaware of the recommendation, even though 87.5% (n=49) of them were actively treating patients with suspected INOCA.
Implementation facilitators were primarily user-driven, including perceived support for diagnosis (89.7%) and treatment (98.7%), while major barriers were organizational, including absent institutional policies (74.4%) and lack of designated coordinators (65.4%).
Familiarity with the recommendation was independently associated with perceived knowledge gains (B = 0.54, 95% CI 0.24–0.84), communication confidence (B = 0.47, 95% CI 0.14–0.80), and female gender (men: B = -0.47, 95% CI -0.86 to -0.09).

Study Design

Type

Cross-Sectional (n=134)

Multicenter

Yes

Structured PICO

What are the key barriers, facilitators, and attitudinal determinants associated with the familiarity and uptake of the national INOCA recommendation among Dutch cardiologists?

P

Population

134 practicing cardiologists in the Netherlands (34.3% female, 94.8% treating patients with suspected INOCA) participating in a cross-sectional national online survey between April and September 2025.

E

Exposure

Exposure to and implementation of the 2020 Dutch Society for Cardiologists (NVVC) national recommendation for diagnostics and treatment of Ischaemia with Non-Obstructive Coronary Arteries (INOCA), assessed via attitudinal statements and the Measurement Instrument for Determinants of Innovation (MIDI) questionnaire.

O

Outcome

Facilitators and barriers to implementation of the NVVC INOCA recommendation (defined using ≥80% agreement and ≥20% disagreement MIDI thresholds, respectively) and self-reported familiarity with the recommendation.

Main Result

Effect estimate: B = 0.54 (perceived improvement in knowledge predicting familiarity) (95% CI 0.24-0.84)

p-value: p=<0.05

Limitations

Low response rate of approximately 12% (134 of 1100 registered Dutch cardiologists), limiting generalizability and likely overrepresenting cardiologists interested in INOCA
Sensitivity of the 80%/20% classification thresholds used in the MIDI questionnaire for near-threshold items
Familiarity with the recommendation was assessed using a single self-reported item rather than a validated multi-item scale
Relatively small sample size for the multivariable regression model (n=78), falling below conservative participant-to-predictor ratio benchmarks
Potential social desirability bias in responses to attitudinal items and lack of direct objective assessment of institutional policies
Low response rate of approximately 12% (134 of 1100 registered Dutch cardiologists), introducing potential selection bias toward more engaged clinicians
Boundary sensitivity of the 80%/20% thresholds used to classify MIDI facilitators and barriers
Single-item self-reported measure used to operationalize familiarity with the recommendation
Modest sample size (n=78) for the multivariable regression analysis
Potential social desirability bias and lack of direct institutional policy verification

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Answers are grounded in this paper and cite their sources.

Implication

Despite high individual motivation and frequent clinical exposure to INOCA patients, uptake of national INOCA guidance among Dutch cardiologists is hindered by substantial unawareness (42%) and a lack of institutional policies, coordinators, and feedback mechanisms.

Abstract

Background: In 2020, the Dutch Society for Cardiologists (NVVC) published a national recommendation for diagnostics and treatment of Ischaemia with Non-Obstructive Coronary Arteries (INOCA), a historically underrecognized condition. In this study we identify determinants of implementation of the NVVC INOCA recommendation through a national survey among Dutch cardiologists. Methods: We performed a cross-sectional, nationwide online survey among Dutch cardiologists, incorporating attitudinal statements derived from prior qualitative research and the Measurement Instrument for Determinants of Innovation (MIDI) questionnaire. Descriptive analyses were used to identify facilitators and barriers to implementation. Multiple regression analyses examined associations between attitudinal factors and familiarity with the recommendation. Results: A total of 134 cardiologists participated in this study with 78 (58%) completing the long version of the questionnaire and 56 (42%) the short version. Facilitators for implementation were predominantly user-related, driven by positive outcome expectations, perceptions of professional responsibility, and perceived communicative capabilities. In contrast, key barriers were primarily organizational, including the absence of institutional policies, implementation coordination, and performance feedback. Familiarity with the recommendation was independently associated with perceived improvements in INOCA-related knowledge, confidence in communicating under clinical uncertainty, and gender. Conclusions: Uptake of the NVVC INOCA recommendation among Dutch cardiologists is largely motivated by individual professional commitment and positive outcome expectations but is constrained by limited organizational support. Strengthening institutional implementation structures and reinforcing professional communicative capabilities may help translate high individual motivation into consistent peer-dissemination and recommendation-concordant INOCA care.

Discussion

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Cite This Study

Göttgens et al. (2026) conducted a cross-sectional in Implementation of Ischaemia with Non-Obstructive Coronary Arteries (INOCA) national recommendation among cardiologists (n=134). Dutch Society for Cardiologists (NVVC) national INOCA recommendation uptake and attitudinal determinants was evaluated on Determinants (facilitators and barriers) of NVVC INOCA recommendation implementation and factors associated with recommendation familiarity (B = 0.54 (perceived improvement in knowledge predicting familiarity), 95% CI 0.24-0.84, p=<0.05). Among 134 Dutch cardiologists, 42% were unaware of or had not read the national INOCA guideline, with uptake driven by user expectations (89.7-98.7%) but hindered by lacking institutional policies (74.4%).

synapsesocial.com/papers/6aee6b6871a75948062208e2 https://doi.org/10.1016/j.ijcrp.2026.200718

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Barriers and facilitators for the uptake of the national INOCA recommendation among Dutch cardiologists: A survey study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Barriers and facilitators for the uptake of the national INOCA recommendation among Dutch cardiologists: A survey study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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