Four pillars of HFrEF: pilot study with real-world data

Abstract Background Heart failure is a diagnosis that affects more than 64 million people worldwide. In such patients, the risk of rehospitalisation and death is extremely high, and the quality of life is significantly reduced. The current ESC guidelines recommend four pillars of drugs for heart failure with reduced ejection fraction: 1. angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB) or angiotensin receptor–neprilysin inhibitors (ARNi), 2. beta-blockers (BB), 3. mineralocorticoid receptor antagonists (MRA), 4. sodium–glucose cotransporter 2 inhibitors (SGLT2i). Purpose Despite scientific advances and the availability of guideline-directed medical therapy (GDMT), outcomes have not improved significantly. One of the main reasons is the lack of therapy introduction and poor initiation, up-titration and adherence. The aim of this pilot study was to investigate how prone we are in our institution to introduce GMDT therapy in patients with HFrEF and what are the main reasons for omitting the recommended therapy. Methods The aim is to provide a comprehensive data set about HFrEF patients hospitalized due to acute heart failure (AHF). Extensive baseline data including medical history, laboratory tests and therapy were collected, as diagnostic and therapeutic decisions during the baseline AHF event and changes in therapy. Results Between 1 July 2025 and 30 September 2025, 82 patients were enrolled from a single centre. All of the patients were hospitalised due to AHF, of which 42.68% were first time hospitalised. They were 63.41% male and the age was 73 (61-80). Initially 60.97% of patients had RAAS/ARNi, 56% (BB), 41.46% MRA and 39.02% SGLT2i. At the time of discharge from the hospital, as many as 89.02% of patients were on RAASi/ARNi, 93.9% beta blockers, 90.24% MRA and 80.48% SGLT2i. When assessing the contraindications for the introduction of GDMT, 63.41% of patients had no contraindications for any of the four pillars of therapy. The most common contraindication for not introducing SGLT2 was urinary tract infection in 8.53% and renal insufficiency in 7.31%. Among the contraindications for introducing RAASi/ARNi and BB was hypotension in 3.65% of cases and bradycardia in 2.43%. By examining the medical documentation, in 12.19% of cases, no evident contraindication was found for one of the 4 drugs that was not introduced. Conclusion With this pilot study, we wanted to present real-world data when talking about patients with HFrEF and the daily clinical challenges we face in treating these patients. From the above, it is evident that the implementation of GDMT is at a high level, but we are aware that there is also a significant number of situations when all necessary therapy is not introduced without a clear contraindication. In order to better understand the clinical practice of treating patients with heart failure, it is necessary to expand this study and continue to monitor the patients.