Resource and knowledge gaps drive limited assessment of inflammation, leading to diagnostic and treatment delays in heart failure patients: findings from Brazil, Israel, and Saudi Arabia
W Al Habeeb, Mosaad Alhussein, Yaron Arbel, Nancy T Coelho, Luiz Claudio Danzmann, Francisco Fonseca, Shlomi Matetzki, Monica M M Mathias, Raul D Santos, Islam Tawfik, Lidia Ana Zytynski, Oren CaspiAbstract
Background/Introduction
Heart failure with preserved ejection fraction (HFpEF) and mildly reduced ejection fraction (HFmrEF) are increasingly recognized as systemic syndromes, characterized not only by diverse cardiovascular abnormalities but also by a significant inflammatory component. Systemic inflammation is now understood to play a pivotal role in the pathogenesis, progression, and outcomes of heart failure. Among available biomarkers, C-reactive protein (CRP)—including wide-range (wrCRP) and high-sensitivity (hsCRP) assays—offers a practical means to assess inflammatory risk in HF patients. Despite its clinical relevance, CRP testing remains underutilized, often due to cost, limited resources, and insufficient awareness among clinicians.
Purpose
This study evaluated the availability of resources, diagnostic practices, and—most critically—access and barriers to CRP testing for HFpEF/HFmrEF patients in Saudi Arabia, Israel, and Brazil. The goal was to highlight the importance of systemic inflammation assessment and the need for broader adoption of CRP testing in routine heart failure care.
Methods
A web-based survey was conducted among 260 clinicians (Saudi Arabia n=80, Israel n=95, Brazil n=85). Each participant submitted three patient record forms (total=780) for their most recent HFpEF/HFmrEF cases, providing a robust dataset for analysis of diagnostic and testing practices.
Results
Clinicians estimated that 38% of HFpEF/HFmrEF patients remain undiagnosed, largely due to mild or concealed symptoms. Crucially, 22% of respondents reported low diagnostic resources, with this challenge more pronounced in Saudi Arabia (31%) and Israel (23%) compared to Brazil (11%). Limited resources and knowledge directly impacted the likelihood of clinicians considering systemic inflammation during diagnosis (p<0.05). Access to CRP testing was notably restricted: only 57% could order standard CRP, 4% had access to wrCRP, and 31% to hsCRP. Israeli clinicians reported lower access to both hsCRP and standard CRP compared to their counterparts in Saudi Arabia and Brazil. The main barriers to CRP testing included limited availability (37%), cost (31%), lack of awareness of clinical relevance (29%), limited experience (28%), and insurance coverage issues (27%).
Conclusions
A substantial proportion of HFpEF and HFmrEF cases remain unrecognized, not only due to subtle clinical manifestations but also because of constrained care pathways and limited clinician awareness of systemic inflammation’s role. Insufficient understanding of HFpEF/HFmrEF among healthcare professionals delays symptom recognition, appropriate testing including CRP measurement and specialist referral, resulting in fragmented and delayed diagnosis and management. Although CRP measurement is not yet mandated for HF diagnosis, it provides valuable insights into inflammation-related risk, supporting patient stratification and prognostic evaluation.For image description, please refer to the figure legend and surrounding text.