ESC Congress 2026 Abstract · Oct 26, 2026

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

By Khunti K, Lam CSP, Pollock C et al.

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.

doi.org/10.1093/eurheartj/ehag785.1315Open accessPopulations