Savarese, Gianluigi (36189499900)Gianluigi (36189499900)SavareseLindberg, Felix (57451813800)Felix (57451813800)LindbergChristodorescu, Ruxandra M. (8203870600)Ruxandra M. (8203870600)ChristodorescuFerrini, Marc (7003272884)Marc (7003272884)FerriniKumler, Thomas (6508270317)Thomas (6508270317)KumlerToutoutzas, Konstantinos (58963510800)Konstantinos (58963510800)ToutoutzasDattilo, Giuseppe (24073159500)Giuseppe (24073159500)DattiloBayes-Genis, Antoni (58760048400)Antoni (58760048400)Bayes-GenisMoura, Brenda (6602544591)Brenda (6602544591)MouraAmir, Offer (24168088800)Offer (24168088800)AmirPetrie, Mark C. (57222705876)Mark C. (57222705876)PetrieSeferovic, Petar (55873742100)Petar (55873742100)SeferovicChioncel, Ovidiu (12769077100)Ovidiu (12769077100)ChioncelMetra, Marco (7006770735)Marco (7006770735)MetraCoats, Andrew J.S. (35395386900)Andrew J.S. (35395386900)CoatsRosano, Giuseppe M.C. (7007131876)Giuseppe M.C. (7007131876)Rosano2025-06-122025-06-122024https://doi.org/10.1002/ejhf.3214https://www.scopus.com/inward/record.uri?eid=2-s2.0-85189106112&doi=10.1002%2fejhf.3214&partnerID=40&md5=4722be151c38a7259e7f29ab6f44c133https://remedy.med.bg.ac.rs/handle/123456789/1128Aims: Recent guidelines recommend four core drug classes (renin–angiotensin system inhibitor/angiotensin receptor–neprilysin inhibitor [RASi/ARNi], beta-blocker, mineralocorticoid receptor antagonist [MRA], and sodium–glucose cotransporter 2 inhibitor [SGLT2i]) for the pharmacological management of heart failure (HF) with reduced ejection fraction (HFrEF). We assessed physicians' perceived (i) comfort with implementing the recent HFrEF guideline recommendations; (ii) status of guideline-directed medical therapy (GDMT) implementation; (iii) use of different GDMT sequencing strategies; and (iv) barriers and strategies for achieving implementation. Methods and results: A 26-question survey was disseminated via bulletin, e-mail and social channels directed to physicians with an interest in HF. Of 432 respondents representing 91 countries, 36% were female, 52% were aged <50 years, and 90% mainly practiced in cardiology (30% HF). Overall comfort with implementing quadruple therapy was high (87%). Only 12% estimated that >90% of patients with HFrEF without contraindications received quadruple therapy. The time required to initiate quadruple therapy was estimated at 1–2 weeks by 34% of respondents, 1 month by 36%, 3 months by 24%, and ≥6 months by 6%. The average respondent favoured traditional drug sequencing strategies (RASi/ARNi with/followed by beta-blocker, and then MRA with/followed by SGLT2i) over simultaneous initiation or SGLT2i-first sequences. The most frequently perceived clinical barriers to implementation were hypotension (70%), creatinine increase (47%), hyperkalaemia (45%) and patient adherence (42%). Conclusions: Although comfort with implementing all four core drug classes in patients with HFrEF was high among physicians, a majority estimated implementation of GDMT in HFrEF to be low. We identified several important perceived clinical and non-clinical barriers that can be targeted to improve implementation. © 2024 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.Guideline-directed medical therapyHeart failure with reduced ejection fractionTreatment implementation