Enhancing implementation of evidence-based heart failure therapies in clinical practice: vital to modern medicine

We are thrilled to have the opportunity to explore this focused issue in Cardiology Plus, delving into the obstacles and challenges surrounding the adopting new guideline-directed medical therapy (GDMT) for patients with heart failure (HF)1–3. HF affects millions worldwide, presenting as a highly dominant and severe chronic condition. Despite the continuous evolution of new medications, implantable technologies, home-based care, and rehabilitation approaches, the burden of morbidity and mortality associated with HF remains substantial. Unfortunately, this burden has persisted over decades, indicating persistent gaps in implementing therapeutic advancements. In both inpatient and outpatient settings, the optimization of treatment appears slow, irregular, unequal, and incomplete. Shockingly, the utilization of GDMT in routine clinical practice remains remarkably low, with discontinuation rate of mineralocorticoid receptor antagonists (MRA) reaching as high as 42%4–5. In the EVOLUTION HF study, encompassing patients initiating any GDMT within 12 months of post-hospitalization for HF, the initiation of novel GDMT is often delayed, with few patients receiving target doses necessitating uptitration among the 266,589 patients6. Consequently, in our real-world cohort of patients with HF, we observe frequent hospital readmissions during the early post-discharge period, primarily attributed to worsening HF. Notably, 60.1% of readmissions occurred within the first quarter following the index hospitalization. The 1-year readmission rate related to HF was 38.4%, and worsening HF constituted 63% of all-cause readmissions7. What causes this gap to exist? What is the reason behind the persistence of these long-standing implementation gaps? Is our healthcare system unable to keep pace with new knowledge and technology, failing to apply them in everyday practice? Or are more advanced knowledge and technology and more effective treatments needed? It seems likely that the health system struggles to keep pace with advancements, leading to this discrepancy. Looking back over the past two decades, there has been minimal improvement in the clinical implementation of GDMT. Numerous significant obstacles persist, including clinician awareness gaps, inertia, and a disparity between knowledge and action in healthcare. Additionally, poor interoperability of patient monitoring technologies exacerbates these challenges. Addressing this implementation gap is imperative for public health. This issue highlights key factors contributing to the gap, offering insights into the complexities of real-world application. Efforts to bridge this divide between knowledge and practice are crucial to enhancing patient outcomes and optimizing HF management in clinical settings. What strategies can we use to overcome obstacles and achieve successful implementation? Although today's guidelines highlight the importance of better clinical implementation, they often lack details information on how to operationalize recommendations. What is our starting point? Early initiation of GDMT of HF with reduced ejection fraction (HFrEF) medications, including initiation during hospital stays. This presents a valuable opportunity for a good start by monitoring, for example, vital parameters (blood pressure, heart rate), electrolytes, and renal function. Numerous well-conducted clinical trials, including the process for assessment of carvedilol therapy for heart failure (IMPACT-HF), angiotensin neprilysin inhibitor in acute decompensated heart failure (PIONEER-HF), sotagliflozin in patients with diabetes and recent worsening heart failure (SOLOIST-WHF), empagliflozin in patients hospitalized for acute heart failure (EMPULSE), and dapagliflozin and effect on cardiovascular events in acute heart failure (DAPA ACT-HF) trials, have documented the efficacy of in-hospital or immediate post-discharge initiations of evidence-based therapies for HFrEF8–12. For instance, the STRONG-HF trial demonstrated that an intensive treatment strategy involving rapid uptitration of GDMT to 100% of recommended doses within 2 weeks of discharge, coupled with close follow-up after acute HF admission, effectively alleviated symptoms, improved quality of life and reduced the risk of 180-day all-cause death or HF readmission compared to usual care13. Certainly, the brief in-hospital stay for patients with HF poses challenges for initiating and adjusting medications. Additionally, healthcare encounters like outpatient visits, remote HF medication titration clinics, home medication delivery, or nursing support at home are essential for medication adjustment and monitoring. Therefore, there is a need for structured, evidence-based guidance to optimize implementation strategy to encompass all aspects of the healthcare system. This optimized strategy should include active recruitment for early post-discharge follow-up, systematic and scheduled outpatient visits, and measures to overcome physicians' clinical inertia. Established tools for assessing medication tolerability and the integration of holistic care by multidisciplinary teams are crucial. Referral to nurse-led clinics has shown to provide survival benefits in real-world practice14. Socioeconomic interventions should also be integrated into the holistic care of patients with HF. All these actions should be undertaken in a person-centered and personalized manner. In Sweden, the government is launching a nationwide person-centered, coherent care process for HF to ensure the well-being of all HF patients15. This initiative reflects a comprehensive approach to address the multifaceted needs of individuals living with HF. The optimal execution of GDMT is expected to prolong event-free survival and improve quality of life. The question is, what can be done to achieve this objective? We are now in the middle of promoting clinical implementation and care delivery science worldwide that strives to achieve better optimal medical therapy for our HF patients in everyday practice. A widespread discussion and understanding of what we can do to optimize HF care are essential. We are confident that this targeted issue will successfully serve its purpose. Indeed in order to further reduce the risk of HF rehospitalization or death, and improve quality of life in patients with HF, there remains a substantial unmet need of early initiation and rapid up-titration of GDMT. This include the adoption of novel treatments such as angiotensin receptor neprilysin inhibitor (ARNi) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) as the default strategy within the first 6 weeks following an HF hospitalization, as recommended by the latest guideline1. This comprehensive four-drug strategy has demonstrated remarkable outcomes, including an additional 8.3 years free from cardiovascular death or first HF hospital admission, as well as 6.3 additional years of survival16. The evidence supporting the efficacy of this approach underscores the urgency and importance of promptly implementing these advancements in clinical practice. By embracing early initiation and aggressive up-titration of GDMT, particularly with novel therapies, healthcare providers can significantly improve patient outcomes and prolong survival while enhancing the overall management of HF. We encourage and appreciate all efforts aimed at closing implementation gaps through open discussion, rigorous study and thorough evaluation. We believe that a successful conceptual framework will soon become a reality that will improve knowledge uptake, foster the speedy translation from evidence to care and engage policymakers, researchers and clinicians who have roles in HF care. Improving clinical implementation of evidence-based therapies for HF in real-world clinical practice is ready for prime time and fundamentally vital for the modern era of medical science. CONFLICT OF INTEREST STATEMENT Michael Fu is currently an Associate Editor of Cardiology Plus. The article was subject to the journal's standard procedures, with peer review handled independently of the Editorial Board members and their research groups. DATA SHARING STATEMENT Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.