Clinical approaches in heart failure: perspective of cardiologists in turkiye (HF-PERSPECTIVE)
T Sen, M Demir, C N Batak, Ö Yidirimturk, H Kaya, K M Aslanger, Z Bayram, A K Kalkan, ÖA Karakas, B Simsek, Z E Osma, A Bozkurt, B Kurtuldu, Z Kocadag, M YildizAbstract
Objective
To evaluate real-world clinical practices of cardiologists in Türkiye in the management of heart failure with reduced ejection fraction (HFrEF) and to identify physician-related differences in diagnostic, therapeutic, and follow-up strategies. This survey also aims to characterize variations in the implementation of guideline-directed medical therapy (GDMT) and to determine the key barriers that contribute to practice variability across diverse healthcare settings.
Methods
A nationwide, cross-sectional, web-based survey was conducted between March and June 2025 among cardiology residents, specialists, and academic faculty. The 28-item questionnaire assessed six domains: demographics, guideline awareness and implementation, pharmacologic therapy patterns, follow-up and monitoring strategies, perceived barriers to GDMT, and institutional variability. Descriptive and comparative analyses were performed using MedicReS statistical software.
Results
A total of 495 cardiologists from all seven regions of Türkiye participated. Most worked in tertiary centers, and 35.5% held academic positions. Regarding therapeutic prioritization, 64% selected ARNI as the single most essential HFrEF medication. In acute de novo HF, 63% preferred ARNI over ACE inhibitors, whereas in the outpatient setting this proportion declined to 45.1%. Heart failure specialists consistently demonstrated the highest ARNI adoption across scenarios. SGLT2 inhibitors were widely implemented, with 94.9% initiating therapy during hospitalization or at discharge.Target or maximum tolerated doses of foundational therapies were achieved within 1–3 months by 48.5% of clinicians, while an additional 27.9% required 3–6 months. Only a minority (14.7%) reached optimization within 1 month. Objective decongestion tools were underused: only 31.1% routinely measured urinary sodium. Conversely, 62.4% reported frequent use of acetazolamide as an adjunct diuretic strategy. Iron deficiency screening was common (86.1%), and 90.5% adhered to guideline-based criteria for IV iron therapy. Clinical signs—rather than biomarkers—guided discharge decisions in 90.9% of cases. Only one-third of respondents had access to cardiac rehabilitation services.
Conclusion
Despite excellent awareness of international HF guidelines, significant gaps remain between evidence and practice in Türkiye. Delayed GDMT initiation and titration, limited use of objective decongestion tools, reimbursement barriers, and heterogeneous ARNI adoption highlight the need for national strategies to support structured HF pathways, improve institutional resources, expand insurance coverage, and accelerate the dissemination of contemporary evidence.Figure 1:Timeline of trials and surveysFor image description, please refer to the figure legend and surrounding text.Figure 2For image description, please refer to the figure legend and surrounding text.