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Many people with HFrEF do not receive all recommended medicines at target doses

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.

Also called HFrEF medicine gaps

  • Bottleneck
  • In this atlas

Overview

Technical summary

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.

Scope

US outpatients with chronic heart failure with reduced ejection fraction, as sampled by the CHAMP-HF registry

Stage
Prescribing and dose step-up after heart failure with reduced ejection fraction is diagnosed
Why it is severe
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

  • Burden Observational Certainty not assessed

    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.

    Applies to Adult
    • 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).
    • Outpatient primary care and cardiology practices (abstract).
    • United States (abstract).
    • Adults; mean age 66 years (abstract).
    Follow-up The abstract describes baseline medicine use and dose; it gives no follow-up period and no enrollment dates.
    Certainty method
    Not assessed
    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.
    Last checked
    2026-10-14
    Next evidence check due
    Not scheduled
    Sources and citations (7)

    1. Supports Medical Therapy for Heart Failure With Reduced Ejection Fraction: The CHAMP-HF Registry

      Publication · Journal of the American College of Cardiology · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2018-07-24 · DOI: 10.1016/j.jacc.2018.04.070 · PMID: 30025570

      Locator
      Abstract, RESULTS, sentence 1
      How it applies
      Registry size and practices. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      1082951ebf6f67d115b7013565a13ca7024dbceaeab43e50c4baadbd511322ed
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    2. Supports Medical Therapy for Heart Failure With Reduced Ejection Fraction: The CHAMP-HF Registry

      Publication · Journal of the American College of Cardiology · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2018-07-24 · DOI: 10.1016/j.jacc.2018.04.070 · PMID: 30025570

      Locator
      Abstract, RESULTS, sentence 3
      How it applies
      Share of eligible patients not prescribed each class. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      1082951ebf6f67d115b7013565a13ca7024dbceaeab43e50c4baadbd511322ed
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    3. Supports Medical Therapy for Heart Failure With Reduced Ejection Fraction: The CHAMP-HF Registry

      Publication · Journal of the American College of Cardiology · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2018-07-24 · DOI: 10.1016/j.jacc.2018.04.070 · PMID: 30025570

      Locator
      Abstract, RESULTS, sentence 4
      How it applies
      Share at target doses among those prescribed. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      1082951ebf6f67d115b7013565a13ca7024dbceaeab43e50c4baadbd511322ed
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    4. Supports Medical Therapy for Heart Failure With Reduced Ejection Fraction: The CHAMP-HF Registry

      Publication · Journal of the American College of Cardiology · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2018-07-24 · DOI: 10.1016/j.jacc.2018.04.070 · PMID: 30025570

      Locator
      Abstract, RESULTS, sentence 5
      How it applies
      Share at target doses of all classes. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      1082951ebf6f67d115b7013565a13ca7024dbceaeab43e50c4baadbd511322ed
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    5. Background Medical Therapy for Heart Failure With Reduced Ejection Fraction: The CHAMP-HF Registry

      Publication · Journal of the American College of Cardiology · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2018-07-24 · DOI: 10.1016/j.jacc.2018.04.070 · PMID: 30025570

      Locator
      Abstract, RESULTS, sentence 6
      How it applies
      Factors tied to lower use or dose. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      1082951ebf6f67d115b7013565a13ca7024dbceaeab43e50c4baadbd511322ed
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    6. Supports Medical Therapy for Heart Failure With Reduced Ejection Fraction: The CHAMP-HF Registry

      Publication · Journal of the American College of Cardiology · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2018-07-24 · DOI: 10.1016/j.jacc.2018.04.070 · PMID: 30025570

      Locator
      Abstract, CONCLUSIONS, sentence 1
      How it applies
      The authors' conclusion. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      1082951ebf6f67d115b7013565a13ca7024dbceaeab43e50c4baadbd511322ed
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    7. Background Medical Therapy for Heart Failure With Reduced Ejection Fraction: The CHAMP-HF Registry

      Publication · Journal of the American College of Cardiology · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2018-07-24 · DOI: 10.1016/j.jacc.2018.04.070 · PMID: 30025570

      Locator
      Abstract, METHODS, sentence 1
      How it applies
      Who was included. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      1082951ebf6f67d115b7013565a13ca7024dbceaeab43e50c4baadbd511322ed
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

Current efforts

None stated in this record.

Record details

Record id
cardio:bottleneck-hfref-medicine-gaps
Content hash
55fb77adccaa3731068a48b4367dad335ff2cbab3bec8faf4c0c33c46f68ef97