Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) is centered on 4 foundational drug classes: renin–angiotensin system inhibition (ACE inhibitor/ARB or angiotensin receptor–neprilysin inhibitor [ARNI]), evidence-based beta-blockers, mineralocorticoid receptor antagonists (MRAs), and sodium–glucose cotransporter-2 inhibitors (SGLT2i). , Despite strong evidence and contemporary guideline recommendations, real-world adoption, sequencing, and speed of up-titration remain variable across health systems and clinician profiles. However, registry data—such as those from ESC-HF-LT, CHAMP-HF, QUALIFY, and REPORT-HF—have consistently demonstrated underutilization of GDMT in real-world practice. ,, We aimed to describe contemporary practice patterns among cardiologists in Türkiye regarding initiation, sequencing, and optimization of foundational therapies, and key in-hospital/outpatient management strategies relevant to HFrEF.
HF-PERSPECTIVE was a nationwide, descriptive, cross-sectional, web-based survey conducted between March and June 2025. Cardiologists practicing in Türkiye (residents, specialists, and academic faculty) were invited via professional communication channels and digital platforms. A structured 28-item questionnaire was developed after review of guideline and registry literature, and piloted for clarity. Domains included participant characteristics, guideline implementation patterns, preferences for ARNI and SGLT2i use in acute de novo HF and outpatient HFrEF, drug sequencing when simultaneous initiation was not feasible, time to achieve target/maximally tolerated GDMT doses, diuretic/decongestion strategies, discharge criteria, follow-up timing, iron deficiency management, and access to cardiac rehabilitation services. Responses were summarized using descriptive statistics; categorical and continuous variables were compared using chi-square and t-tests as appropriate, with p <0.05 considered statistically significant. The study was conducted in accordance with the Declaration of Helsinki and was approved by the Kütahya Health Sciences University Noninterventional Clinical Research Ethics Committee (Decision No. 2025/02; February 11, 2025). No industry support was provided.
A total of 495 cardiologists from all 7 geographical regions of Türkiye participated (66.5% male; mean age 37.4 years). Nearly half worked in training and research hospitals (48.5%), followed by university hospitals (32.5%). Heart failure was reported as a focused field of interest by 11.5% of respondents; 24.4% were cardiology residents ( Table ).
Table
Characteristics of survey participants
| Overall | |
|---|---|
| Age (years) ± SD (min-max) | 37.4 ± 9.2 (20-74) |
| Sex n (%) | |
| Female | 166 (33.5) |
| Male | 329 (66.5) |
| Geographic distribution of participants (%) | |
| Marmara region | 157 (31.7) |
| Central Anatolia | 113 (22.8) |
| Aegean region | 82 (16.6) |
| Black Sea region | 48 (9.7) |
| Mediterranean region | 43 (8.7) |
| Eastern Anatolia region | 31 (6.3) |
| Southeastern Anatolia region | 21 (4.2) |
| Institutional distribution (%) | |
| Training and research hospitals or city hospitals | 240 (48.5) |
| University hospitals | 161 (32.5) |
| Private hospitals | 47 (9.5) |
| State hospitals | 43 (8.7) |
| Private outpatient clinics | 4 (0.8) |
| Main interest n (%) | |
| Cardiology resident | 121 (24.4) |
| General or clinical cardiology | 114 (23) |
| Interventional cardiologist | 99 (20) |
| Heart failure specialists | 57 (11.5) |
| Electrophysiologist | 43 (8.7) |
| Cardiac imaging specialists | 34 (6.9) |
| Other cardiology | 27 (5.5) |
| Academic titles n (%) | |
| Professor | 67 (13.5) |
| Associated professor | 79 (16) |
| Assistant professor | 31 (6.3) |
| Cardiology specialist | 133 (26.9) |
| Cardiology resident | 185 (37.4) |
SD = standard deviation.
In hospitalized patients with acute de novo HF, 63% reported preferring to initiate ARNI rather than an ACE inhibitor when feasible; this preference decreased in the outpatient setting, where 45.1% reported initiating ARNI first. Similarly, 46.5% reported switching eligible outpatients from ACE inhibitor/ARB to ARNI irrespective of functional class. In ARNI-naive patients, most respondents (83.8%) started at 24/26 mg twice daily; among those previously treated with ACE inhibitor/ARB, 54.7% started at 49/51 mg twice daily. SGLT2i adoption in the acute setting was high: 94.9% reported initiating or recommending an SGLT2i during hospitalization or at discharge for acute de novo HF ( Figure ). The majority of cardiologists adhered to a conventional initiation order, starting with ACEi or ARNI (n = 293, 59.2%), followed by beta-blockers (n = 261, 52.7%), MRAs (n = 276, 55.8%), and SGLT2 inhibitors (n = 289, 58.4%), indicating that the historical sequencing paradigm continues to shape real-world prescribing behavior ( Figure ). When asked to choose a single therapy if only 1 drug would be available for HFrEF, 64% selected ARNI, followed by SGLT2i (18.2%), beta-blockers (12.5%), and MRAs (5.3%) ( Figure ).
