Are Hospitalized or Ambulatory Patients With Heart Failure Treated in Accordance With European Society of Cardiology Guidelines?

Evidence From 12 440 Patients of the ESC Heart Failure Long-term Registry

Aldo P. Maggioni; Stefan D. Anker; Ulf Dahlström; Gerasimos Filippatos; Piotr Ponikowski; Faiez Zannad; Offer Amir; Ovidiu Chioncel; Marisa Crespo Leiro; Jaroslaw Drozdz; Andrejs Erglis; Emir Fazlibegovic; Candida Fonseca; Friedrich Fruhwald; Plamen Gatzov; Eva Goncalvesova; Mahmoud Hassanein; Jaromir Hradec; Ausra Kavoliuniene; Mitja Lainscak; Damien Logeart; Bela Merkely; Marco Metra; Hans Persson; Petar Seferovic; Ahmet Temizhan; Dimitris Tousoulis; Luigi Tavazzi; on behalf of the Heart Failure Association of the ESC (HFA)


Eur J Heart Fail. 2013;15(10):1173-1184. 

In This Article

Abstract and Introduction


Aims To evaluate how recommendations of European guidelines regarding pharmacological and non-pharmacological treatments for heart failure (HF) are adopted in clinical practice.

Methods and results The ESC-HF Long-Term Registry is a prospective, observational study conducted in 211 Cardiology Centres of 21 European and Mediterranean countries, members of the European Society of Cardiology (ESC). From May 2011 to April 2013, a total of 12 440 patients were enrolled, 40.5% with acute HF and 59.5% with chronic HF. Intravenous treatments for acute HF were heterogeneously administered, irrespective of guideline recommendations. In chronic HF, with reduced EF, renin–angiotensin system (RAS) blockers, beta-blockers, and mineralocorticoid antagonists (MRAs) were used in 92.2, 92.7, and 67.0% of patients, respectively. When reasons for non-adherence were considered, the real rate of undertreatment accounted for 3.2, 2.3, and 5.4% of the cases, respectively. About 30% of patients received the target dosage of these drugs, but a documented reason for not achieving the target dosage was reported in almost two-thirds of them. The more relevant reasons for non-implantation of a device, when clinically indicated, were related to doctor uncertainties on the indication, patient refusal, or logistical/cost issues.

Conclusion This pan-European registry shows that, while in patients with acute HF, a large heterogeneity of treatments exists, drug treatment of chronic HF can be considered largely adherent to recommendations of current guidelines, when the reasons for non-adherence are taken into account. Observations regarding the real possibility to adhere fully to current guidelines in daily clinical practice should be seriously considered when clinical practice guidelines have to be written.


The therapeutic approaches for hospitalized patients with heart failure (HF) have remained practically unchanged during the last decades. Mainly for this reason, both in-hospital and 1-year outcomes of patients admitted for acute HF are still unacceptably high.[1,2] In contrast, survival of patients with chronic HF seems to improve slowly over time,[1–4] due to the fact that several trials have been conducted in these patients, allowing the inclusion of effective treatments in the recommendations of current guidelines.[5–8] However, several studies showed that treatment guidelines are adopted slowly or are applied inconsistently, often failing to lead to further improvements in patient care quality and outcomes.[9–13]

The ESC-HF Pilot Survey provided a clear picture on the rate of use of guideline-recommended, evidence-based treatments.[14] The rate of use of renin–angiotensin–aldosterone system blockers (ACE inhibitors, ARB, and aldosterone blockers) and beta-adrenergic blockers was satisfactory. However, the number of patients treated with appropriate doses was, at best, suboptimal. With respect to the rate of implantation of devices [CRT devicesand/or implantable cardioverter defibrillators (ICDs)], only a third of patients with the ICD characteristics were actually implanted and one-fifth were treated with CRT.[14] This observation clearly confirmed the relevant gap between recommendations and actual clinical practice.[15] Along the same lines, the EUROMED Registry showed that the implantation rates of ICD and CRT have increased significantly from 2004 to 2008, but underutilization was still present, with major differences across countries.[16]

For all these reasons, one of the major aims of the ESC Long-Term Registry was to evaluate how recommendations of most recent European guidelines regarding pharmacological and non-pharmacological treatments are adopted in clinical practice. More specifically, information on the reasons why evidence-based treatments are not utilized or underdosed with respect to the dosages recommended by guidelines have been collected and reported here.