Temporal trends in guideline-directed medical therapy adoption in heart failure: insights from the iCaReMe global registry

Background

The 2023 European Society of Cardiology (ESC) Focused Update on Heart Failure (HF) marked a pivotal shift, granting Class I recommendations for sodium-glucose co-transporter-2 inhibitors (SGLT2i) across the ejection fraction spectrum. Understanding the real-world uptake of guideline-directed medical therapy (GDMT) in HF, especially in under-represented regions, remains critical for identifying and addressing implementation gaps.

Purpose

To evaluate temporal trends in GDMT adoption and treatment patterns among HF patients, comparing periods before and after the 2023 ESC HF Focused Update.

Methods

This analysis utilised baseline data from the iCaReMe Global Registry HF cohort from 18 countries across Asia-Pacific, Latin America, and Middle East and Africa regions. Two enrolment groups were compared based on the 2023 ESC HF Focused Update release: Period 1 (2020 – August 2023; N=2,434) and Period 2 (September 2023 – 2024; N=713). Patients’ demographic, clinical characteristics, and therapeutic regimens were summarised descriptively and compared using t-tests for continuous variables and Chi-square/Fisher's exact tests for categorical variables.

Results

Overall, 3,147 HF adults (mean age±standard deviation (SD), 59.2±13.02 years; male, 61.0%; HFrEF, 59.5%; HFmrEF, 16.5%; HFpEF, 24.0%) were included, with a mean±SD left ventricular ejection fraction of 40.1±13.91%. Common comorbidities included: hypertension (60.8%), type 2 diabetes mellitus (55.9%), and chronic kidney disease (CKD; 24.7%); 25.3% had prior hospitalisation for HF. Medications included renin-angiotensin system (RAS) blockers (75.7%), beta-blockers (77.2%), mineralocorticoid receptor antagonists (MRA; 52.4%), and SGLT2i (52.2%) (Figure1).

Significant temporal shifts in clinical, demographic, and treatment patterns emerged: compared to Period 1, Period 2 patients were older (mean age, 61.5 vs. 58.5 years; p<0.0001) and had a higher burden of CKD (29.9% vs. 23.0%; p=0.0002). HF phenotype distribution changed: HFrEF proportion decreased (49.5% vs. 62.5%), while HFmrEF (22.4% vs. 14.7%) and HFpEF (28.1% vs. 22.8%) increased (p<0.0001). GDMT adoption improved: SGLT2i use rose (56.2% vs. 51.0%; p=0.0135) as did MRA use (56.5% vs. 51.2%; p=0.0129), with marked increases in SGLT2i for HFmrEF/HFpEF (49.7% vs. 34.8%; p<0.0001). Quadruple therapy (RAS blockers + Beta-blocker + MRA + SGLT2i) in HFrEF showed a positive trend, increasing from 37.9% to 43.3% (p=0.0574) (Figure 2).

Conclusions

This analysis demonstrates encouraging temporal gains in GDMT adoption post-2023 ESC update, particularly SGLT2i and MRA, including expanded SGLT2i use in HFmrEF/HFpEF. However, with quadruple therapy rates remaining below 50% even in HFrEF, substantial gaps persist. These findings highlight the need for continued education, and protocol optimisation to align clinical practice with evidence-based guidelines.