Sequencing and titrating approach of therapy in heart failure with reduced ejection fraction following the 2021 European Society of Cardiology guidelines: an international cardiology survey

Charles Fauvel, Guillaume Bonnet, Wilfried Mullens, Clara Ines Saldarriaga Giraldo, Anja Zupan Mežnar, Anders Barasa, Mariya Tokmakova, Anastasia Shchendrygina, Francisco Moscoso Costa, Massimo Mapelli, Filip Zemrak, Laurens F Tops, Nina Jakus, Arian Sultan, Fadel Bahouth, Chahr-Eddine Hadjseyd, Muriel Salvat, Matteo Anselmino, Daniel Messroghli, Vanessa WeberndörferIlya Giverts, Thomas Bochaton, Emmanuelle Berthelot, Damien Legallois, Florence Beauvais, Fabrice Bauer, Nicolas Lamblin, Thibaud Damy, Nicolas Girerd, Laurent Sebbag, Théo Pezel, Alain Cohen-Solal, Giuseppe Rosano, François Roubille, Nathan Mewton*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

1 Citation (Web of Science)


AIMS: In symptomatic patients with heart failure and reduced ejection fraction (HFrEF), recent international guidelines recommend initiating four major therapeutic classes rather than sequential initiation. It remains unclear how this change in guidelines is perceived by practicing cardiologists versus heart failure (HF) specialists.

METHODS AND RESULTS: An independent academic web-based survey was designed by a group of HF specialists and posted by email and through various social networks to a broad community of cardiologists worldwide 1 year after the publication of the latest European HF guidelines. Overall, 615 cardiologists (38 [32-47] years old, 63% male) completed the survey, of which 58% were working in a university hospital and 26% were HF specialists. The threshold to define HFrEF was ≤40% for 61% of the physicians. Preferred drug prescription for the sequential approach was angiotensin-converting enzyme inhibitors or angiotensin receptor-neprilysin inhibitors first (74%), beta-blockers second (55%), mineralocorticoid receptor antagonists third (52%), and sodium-glucose cotransporter 2 inhibitors (53%) fourth. Eighty-four percent of participants felt that starting all four classes was feasible within the initial hospitalization, and 58% felt that titration is less important than introducing a new class. Age, status in training, and specialization in HF field were the principal characteristics that significantly impacted the answers.

CONCLUSION: In a broad international cardiology community, the 'historical approach' to HFrEF therapies remains the preferred sequencing approach. However, accelerated introduction and uptitration are also major treatment goals. Strategy trials in treatment guidance are needed to further change practices.

Original languageEnglish
Pages (from-to)213-222
Number of pages10
JournalEuropean journal of heart failure
Issue number2
Early online date20 Nov 2022
Publication statusPublished - Feb 2023

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