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  "id": "cardio:bottleneck-hfref-medicine-gaps",
  "owner": "cardio",
  "kind": "bottleneck",
  "slug": "bottleneck-hfref-medicine-gaps",
  "name": "Many people with HFrEF do not receive all recommended medicines at target doses",
  "aliases": [
    "HFrEF medicine gaps"
  ],
  "atlases": [
    "cardio"
  ],
  "summary_plain": "In a US registry of outpatients with heart failure with reduced ejection fraction, many people who could take each recommended medicine class were not prescribed it, and few of those who were prescribed some classes were taking the target dose. Only 1 in 100 of the people who could take all the classes was taking target doses of all of them. The registry authors say strategies to improve the use of these medicines are urgently needed.",
  "summary_technical": "The burden claim rests on the abstract of the CHAMP-HF registry paper (3518 patients, 150 US practices) and nothing else. It describes baseline prescribing at enrollment, gives no enrollment dates, and does not list SGLT2 inhibitors among the classes studied. The abstract says social and economic characteristics were not independently associated with medicine use or dose. The gap is between prescribing and trial doses, and the abstract does not say why. A trial of faster up-titration after a hospital stay is on the idea page.",
  "editorial_state": "draft",
  "last_substantive_edit": "2026-10-14",
  "last_evidence_check": "2026-10-14",
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  "identifiers": [],
  "navigation": {
    "cardio": {
      "system": [
        "heart"
      ],
      "condition-area": [
        "heart-failure"
      ]
    }
  },
  "payload": {
    "stage": "Prescribing and dose step-up after heart failure with reduced ejection fraction is diagnosed",
    "scope": "US outpatients with chronic heart failure with reduced ejection fraction, as sampled by the CHAMP-HF registry",
    "severity_rationale": "The abstract reports that 67% of eligible patients were not prescribed a mineralocorticoid receptor antagonist, and that 1% of those eligible for all classes were taking target doses of all of them. These are registry counts and not a measure of harm.",
    "burden_claims": [
      "cardio:claim-champ-hf-medicine-gaps"
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    "current_efforts": []
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      "category": "burden",
      "statement": "In the CHAMP-HF registry of 3518 US outpatients with chronic heart failure with reduced ejection fraction, many eligible patients were not prescribed each recommended medicine class: 27% were not prescribed an ACE inhibitor, angiotensin receptor blocker or angiotensin receptor neprilysin inhibitor, 33% were not prescribed a beta-blocker and 67% were not prescribed a mineralocorticoid receptor antagonist. Among patients who were prescribed them, few were taking target doses: 17% for ACE inhibitor or angiotensin receptor blocker, 14% for angiotensin receptor neprilysin inhibitor and 28% for beta-blocker, against 77% for a mineralocorticoid receptor antagonist. Of patients eligible for all classes, 1% were taking target doses of all of ACE inhibitor, angiotensin receptor blocker or angiotensin receptor neprilysin inhibitor, a beta-blocker and a mineralocorticoid receptor antagonist at once. The authors conclude that significant gaps in the use and dose of guideline-directed medical therapy remain.",
      "context": {
        "id": "cardio:ctx-champ-hf-us-outpatients",
        "label": "Outpatients in the United States with chronic heart failure and a reduced ejection fraction, taking at least one oral heart-failure medicine (CHAMP-HF registry)",
        "recipient": "adult",
        "population": "Outpatients with chronic heart failure with reduced ejection fraction who were receiving at least one oral medication for heart failure. 3518 patients from 150 primary care and cardiology practices were included. Mean age was 66 years (standard deviation 13), 29% were female, and mean ejection fraction was 29% (standard deviation 8).",
        "care_setting": "Outpatient primary care and cardiology practices (abstract).",
        "geography": "United States (abstract).",
        "life_stage_note": "Adults; mean age 66 years (abstract).",
        "life_stage_terms": null,
        "gestational_age_min_days": null,
        "gestational_age_max_days": null,
        "gestational_age_basis": null,
        "postnatal_age_min_days": null,
        "postnatal_age_max_days": null,
        "gestational_age_status": null,
        "postnatal_age_status": null,
        "followup_description": "The abstract describes baseline medicine use and dose; it gives no follow-up period and no enrollment dates.",
        "eligibility": {
          "inclusion": [
            "Outpatients in the United States",
            "Chronic heart failure with reduced ejection fraction",
            "Receiving at least one oral medicine for heart failure"
          ],
          "exclusion": [
            "Not listed in the abstract"
          ]
        }
      },
      "evidence_stage": "observational",
      "certainty": "not_assessed",
      "certainty_method": null,
      "limitations": "An observational registry of 150 US practices; the numbers come from the PubMed abstract and describe baseline prescribing at enrollment. The abstract gives no enrollment dates, so the claim cannot say how current the figures are, and the abstract does not list SGLT2 inhibitors among the classes studied. It does not say how eligibility for each class was determined or why medicines were not prescribed, and says clinical factors such as older age, lower blood pressure, kidney insufficiency and recent hospitalization generally went with lower use or dose. The full text was not read. No certainty rating was assessed.",
      "editorial_state": "draft",
      "checked_at": "2026-10-14",
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