{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T05:20:44Z","timestamp":1788412844120,"version":"build-2803163510"},"reference-count":40,"publisher":"Oxford University Press (OUP)","issue":"6","license":[{"start":{"date-parts":[[2025,12,5]],"date-time":"2025-12-05T00:00:00Z","timestamp":1764892800000},"content-version":"vor","delay-in-days":623,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"},{"start":{"date-parts":[[2024,3,22]],"date-time":"2024-03-22T00:00:00Z","timestamp":1711065600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2024,6,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Aims<\/jats:title>\n                    <jats:p>Recent guidelines recommend four core drug classes (renin\u2013angiotensin system inhibitor\/angiotensin receptor\u2013neprilysin inhibitor [RASi\/ARNi], beta-blocker, mineralocorticoid receptor antagonist [MRA], and sodium\u2013glucose cotransporter 2 inhibitor [SGLT2i]) for the pharmacological management of heart failure (HF) with reduced ejection fraction (HFrEF). We assessed physicians' perceived (i) comfort with implementing the recent HFrEF guideline recommendations; (ii) status of guideline-directed medical therapy (GDMT) implementation; (iii) use of different GDMT sequencing strategies; and (iv) barriers and strategies for achieving implementation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and results<\/jats:title>\n                    <jats:p>A 26-question survey was disseminated via bulletin, e-mail and social channels directed to physicians with an interest in HF. Of 432 respondents representing 91 countries, 36% were female, 52% were aged &amp;lt;50\u2009years, and 90% mainly practiced in cardiology (30% HF). Overall comfort with implementing quadruple therapy was high (87%). Only 12% estimated that &amp;gt;90% of patients with HFrEF without contraindications received quadruple therapy. The time required to initiate quadruple therapy was estimated at 1\u20132\u2009weeks by 34% of respondents, 1\u2009month by 36%, 3\u2009months by 24%, and\u2009\u22656\u2009months by 6%. The average respondent favoured traditional drug sequencing strategies (RASi\/ARNi with\/followed by beta-blocker, and then MRA with\/followed by SGLT2i) over simultaneous initiation or SGLT2i-first sequences. The most frequently perceived clinical barriers to implementation were hypotension (70%), creatinine increase (47%), hyperkalaemia (45%) and patient adherence (42%).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Although comfort with implementing all four core drug classes in patients with HFrEF was high among physicians, a majority estimated implementation of GDMT in HFrEF to be low. We identified several important perceived clinical and non-clinical barriers that can be targeted to improve implementation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/ejhf.3214","type":"journal-article","created":{"date-parts":[[2024,3,22]],"date-time":"2024-03-22T03:24:13Z","timestamp":1711077853000},"page":"1408-1418","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":65,"title":["Physician Perceptions, Attitudes, and Strategies Towards Implementing Guideline-Directed Medical Therapy in Heart Failure with Reduced Ejection Fraction. A Survey of the Heart Failure Association of the ESC and the ESC Council for Cardiology Practice"],"prefix":"10.1093","volume":"26","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7732-0887","authenticated-orcid":false,"given":"Gianluigi","family":"Savarese","sequence":"first","affiliation":[{"name":"Division of Cardiology, Department of Medicine, Karolinska Institutet , Stockholm ,","place":["Sweden"]},{"name":"Heart, Vascular and Neuro Theme, Karolinska University Hospital , Stockholm ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Felix","family":"Lindberg","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medicine, Karolinska Institutet , Stockholm ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ruxandra M.","family":"Christodorescu","sequence":"additional","affiliation":[{"name":"Department V Internal Medicine, University of Medicine and Pharmacy V. Babes Timisoara, Institute of Cardiology Research Center , Timi\u0219oara ,","place":["Romania"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marc","family":"Ferrini","sequence":"additional","affiliation":[{"name":"Department of Cardiology and Vascular Pathology, CH Saint Joseph and Saint Luc , Lyon ,","place":["France"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"Kumler","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Herlev-Gentofte University Hospital , Copenhagen ,","place":["Denmark"]},{"name":"Steno Diabetes Center Copenhagen \u00a0","place":["Denmark"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Konstantinos","family":"Toutoutzas","sequence":"additional","affiliation":[{"name":"First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, \u2018Hippokration\u2019 General Hospital of Athens , Athens ,","place":["Greece"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppe","family":"Dattilo","sequence":"additional","affiliation":[{"name":"Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina , Messina ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antoni","family":"Bayes-Genis","sequence":"additional","affiliation":[{"name":"Institut del Cor, Hospital Universitari Germans Trias I Pujol , Barcelona ,","place":["Spain"]},{"name":"Centro de Investigaci\u00f3n Biom\u00e9dica en Red de Enfermedades Cardiovasculares (CIBERCV; Departamento de Medicina, Universitat Aut\u00f2noma de Barcelona) , Barcelona ,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brenda","family":"Moura","sequence":"additional","affiliation":[{"name":"Armed Forces Hospital, Faculty of Medicine of the University of Porto , Porto ,","place":["Portugal"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Offer","family":"Amir","sequence":"additional","affiliation":[{"name":"Heart Institute, Hadassah Medical Center & Faculty of Medicine, Hebrew University , Jerusalem ,","place":["Israel"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark C.","family":"Petrie","sequence":"additional","affiliation":[{"name":"Institute of Cardiovascular and Medical Sciences, The University Court of the University of Glasgow , Glasgow ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Petar","family":"Seferovic","sequence":"additional","affiliation":[{"name":"University Medical Center, Medical Faculty University of Belgrade, Serbian Academy of Sciences and Arts , Belgrade ,","place":["Serbia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ovidiu","family":"Chioncel","sequence":"additional","affiliation":[{"name":"Emergency Institute for Cardiovascular Diseases \u2018Prof. C.C. Iliescu\u2019 , Bucharest ,","place":["Romania"]},{"name":"University of Medicine Carol Davila , Bucharest ,","place":["Romania"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marco","family":"Metra","sequence":"additional","affiliation":[{"name":"Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia , Brescia ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew J.S.","family":"Coats","sequence":"additional","affiliation":[{"name":"Heart Research Institute , Sydney ,","place":["Australia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppe M.C.","family":"Rosano","sequence":"additional","affiliation":[{"name":"Cardiovascular Clinical Academic Group, St George's University Hospital , London ,","place":["UK"]},{"name":"Cardiology, IRCCS San Raffaele , Rome ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2024,3,22]]},"reference":[{"key":"2026010913054413400_ejhf3214-bib-0001","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1016\/j.jchf.2021.09.004","article-title":"A systematic review and network meta-analysis of pharmacological treatment of heart failure with reduced ejection fraction","volume":"10","author":"Tromp","year":"2022","journal-title":"JACC Heart Fail"},{"key":"2026010913054413400_ejhf3214-bib-0002","doi-asserted-by":"crossref","first-page":"578","DOI":"10.1002\/ejhf.2141","article-title":"Pharmacotherapy for heart failure with reduced ejection fraction and health-related quality of life: A systematic review and meta-analysis","volume":"23","author":"Turgeon","year":"2021","journal-title":"Eur J Heart Fail"},{"key":"2026010913054413400_ejhf3214-bib-0003","doi-asserted-by":"crossref","first-page":"1326","DOI":"10.1002\/ejhf.1182","article-title":"Factors associated with underuse of mineralocorticoid receptor antagonists in heart failure with reduced ejection fraction: An analysis of 11\u2009215 patients from the Swedish Heart Failure Registry","volume":"20","author":"Savarese","year":"2018","journal-title":"Eur J Heart Fail"},{"key":"2026010913054413400_ejhf3214-bib-0004","doi-asserted-by":"crossref","first-page":"741","DOI":"10.1007\/s10741-021-10077-x","article-title":"Factors associated with non-use and sub-target dosing of medical therapy for heart failure with reduced ejection fraction","volume":"27","author":"Greene","year":"2022","journal-title":"Heart Fail Rev"},{"key":"2026010913054413400_ejhf3214-bib-0005","doi-asserted-by":"crossref","DOI":"10.15420\/cfr.2021.34","article-title":"Evidence-based therapy in older patients with heart failure with reduced ejection fraction","volume":"8","author":"Stolfo","year":"2022","journal-title":"Card Fail Rev"},{"key":"2026010913054413400_ejhf3214-bib-0006","doi-asserted-by":"crossref","first-page":"2129","DOI":"10.1093\/eurheartj\/ehw128","article-title":"2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). 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