Primary care management of chronic heart failure in Germany: prevalence, diagnostics, and guideline-directed therapy in WATCH-HF 1.0 vs 2.0
R Reibis, M Luedde, N Smetak, E Ziegler, T Celer, F Roedicker, S WassmannAbstract
Background
Chronic heart failure (HF) remains frequently underdiagnosed and undertreated in primary care. Using real-world data from German general practices, we assessed HF prevalence, diagnostic practices, and treatment patterns and examined changes between WATCH-HF 1.0 (01/2021–06/2023) and WATCH-HF 2.0 (07/2023–12/2024). For heart failure with reduced ejection fraction (HFrEF), four-pillar guideline-directed medical therapy (GDMT: renin–angiotensin system inhibitors [RASi], beta-blockers [BB], mineralocorticoid receptor antagonists [MRAs], and sodium–glucose cotransporter-2 inhibitors [SGLT2i]) is recommended. Although HF phenotypes could not be identified, HFrEF is expected to account for ~50% of HF cases.
Methods
Within the InspeCKD study framework, WATCH-HF analysed anonymised electronic health records from German primary care practices (1,244 in 1.0; 1,687 in 2.0). Adults with hypertension, diabetes, and cardiovascular disorders, including HF, were included. Data were collected during routine care with ≥1 year of follow-up (mean observation: 1.7 [±0.4] years in 1.0; 1.3 [±0.1] years in 2.0). Outcomes comprised HF prevalence, documented NT-proBNP testing, and use/initiation of GDMT components (RASi, BB, MRAs, SGLT2i) and diuretics. Analyses were descriptive and unadjusted.
Results
In WATCH-HF 1.0, 54,721 of 448,837 were diagnosed with HF (12.2%; 52.8% women; mean age 73.9), vs 54,002 of 452,284 in 2.0 (11.9%; 50.5% women; mean age 74.1). NT-proBNP testing at the time of HF diagnosis was consistently rarely documented (absent in 97.7% in 1.0; 97.8% in 2.0). Use of GDMT increased from 7.4% to 11.5%, primarily driven by SGLT2i use (17.8%→31.1%). Modest increases were observed for BB (66.4%→67.0%) and MRAs (24.0%→25.5%), while RASi and diuretics use remained largely unchanged (RASi 76.2%→75.4%; diuretics 58.6%→57.7%). Among previously untreated HF patients, initiation improved across all drug classes (RASi 24.5%→32.5%; BB 17.5%→28.9%; MRAs 9.2%→14.8%; SGLT2i 8.8%→23.9%; diuretics 27.4%→35.1%). Time to first prescription after HF diagnosis remained prolonged for RASi (6.0 vs 5.9 weeks), BB (6.7 vs 6.3), and diuretics (4.6 vs 4.2), improved slightly for MRAs (6.2 vs 5.7) and substantially shortened for SGLT2i (7.0 vs 5.0 weeks). Women and patients aged ≥80 years were consistently less likely to receive GDMT.
Conclusions
HF management in German primary care improved, reflected by increased uptake of GDMT, particularly SGLT2i, suggesting better translation of guideline recommendations into clinical practice. Nevertheless, NT-proBNP testing remains infrequent; overall GDMT coverage is still suboptimal, and initiation is often delayed, suggesting missed opportunities. Given that four-pillar therapy applies to HFrEF and that about half of HF patients are expected to have HFrEF, targeted, equitable strategies are needed to strengthen diagnostic pathways and accelerate initiation, titration, and persistence of GDMT in primary care.