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Addressing Gaps in Heart Failure Care
Addressing Gaps in Heart Failure Care With Practical Tools and SGLT2 Inhibitors 

Released: September 26, 2025

Javed Butler
Javed Butler, MD, MPH, MBA
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Key Takeaways
  • The most significant missed opportunities in heart failure care are the timely diagnosis of heart failure with preserved ejection fraction and use of aggressive treatment that adhere to guidelines.
  • The multidisciplinary care team, electronic health record, and position papers or guidelines from national organizations are widely available resources that can help address persistent gaps in care.
  • SGLT2 inhibitors offer several benefits to patients with heart failure and can be used across the full ejection fraction spectrum. 

A missed opportunity in the management of patients with heart failure (HF) is the delayed diagnosis of heart failure with preserved ejection fraction (HFpEF). When patients present to the hospital or emergency department with clear symptoms like those of myocardial infarction or myocarditis and the attending healthcare professional (HCP) suspects heart failure with reduced ejection fraction (HFrEF), patients are diagnosed. But those at high risk for HFpEF, such as having comorbid obesity and/or type 2 diabetes, are not diagnosed so swiftly. Although these patients often complain of shortness of breath, HCPs have this mindset of evaluating everything else first. We might rule out chronic obstructive pulmonary disease, asthma, hypothyroidism, and anemia before blaming obesity or aging for patients’ nonspecific symptoms. In this case, HCPs may not consider that 6 months ago these patients did not have these symptoms yet still had the same comorbidities, so something else has changed. Therefore, HCPs must think about HFpEF in their differential diagnosis and order a natriuretic peptide test to confirm the diagnosis. 

Another missed opportunity is waiting for symptoms although HF outcomes are bad. This is because we have made an exception that HF is a symptom-based disease. Now, of course, we must provide symptom improvement for patients, but that is not the point of treatment. We need to treat HF. If patients have hypertension or diabetes or dyslipidemia, how many times are we not going to treat them and say that they are doing okay? Like HF, these diseases are often asymptomatic, but we start treatment anyway. Similarly, we must treat the disease of HF before waiting for symptoms to worsen. When patients say that they are doing okay, we as HCPs do not know what that means. So why should we wait for things to get worse before treating them? Furthermore, the risk of sudden cardiovascular-related death occurs without warning or disease worsening. For all these reasons, aggressive therapy for HF is a missed opportunity.

Gaps in Care Persist Despite Guideline-Directed Medical Therapy
There are 4 reasons for these gaps in care. Reason 1 is that cardiology HCPs often are overworked and have minimal time available for patient appointments—most cardiology offices have full schedules daily. This negatively impacts patient care. Having said that, the answer to the problem is that we cannot let the disease progress by not providing care to patients. We need systematic solutions like care pathways, specialty clinics, and referrals. This is not an insurmountable problem for organizations to address, but we all need the willpower to systematically deal with the problem.

The second reason is the biggest issue: clinical inertia. That is, if patients are not actively complaining, we do not necessarily treat them. That mindset must change regardless of patients’ symptoms. Patients need to be treated appropriately for HF, even if they are doing “okay,” because they need therapy.

The third reason is the cost of care, including health insurance coverage. Guideline-directed medical therapy for HFrEF identifies 4 different drug classes that comprise ideal treatment. Treating with less is still good because treating with something is better than nothing. Regardless, we are being asked to initiate an angiotensin receptor–neprilysin inhibitor (the preferred therapy) or an angiotensin-converting enzyme inhibitor at the least, as well as a beta-blocker, MRA, and SGLT2 inhibitor for HFrEF. Diuretics may be used as needed. These therapies can be used in HF with mildly reduced ejection fraction and HFpEF—though their specific recommendation class varies in the guidelines. HF treatment requires quite the combination of agents, so it is no wonder that cost is an issue. Looking at the opposite side of the coin, cost can be seen as worsening the disease.

The fourth and final reason is that patients push back against us prescribing so many pills at once. The only solution to this is patient education, including taking a few minutes to explain to them why this treatment is crucial to their health.

Strategies to Address Gaps Care
The multidisciplinary team is a double-edged sword. On one end, the team is incredibly helpful. None of these therapies for HF are “rocket science,” meaning we can algorithmically prescribe them in any setting. The problem is that specialists are too busy with procedures and focusing on complex patients, and primary care HCPs may be dealing with too many different diseases at once. Multidisciplinary teams should include clinical pharmacists and advanced practice providers like nurse practitioners with a specialty focus. These HCPs can help with nonpharmacologic treatments like patient education, diet, and exercise. The reason I started by saying it is a double-edged sword is because I do not want to inadvertently give the impression that if primary care does not have this large, integrated team, then they are paralyzed and cannot provide good care. HF therapies are standard medications that primary care can prescribe, but in the absence of that, we can at least give patients good care.

Another strategy consists of the electronic health record (EHR). I grew up in an era where HCPs used paper charts. On Sunday night or Monday morning, it was the nursing staff’s duty to look at all the patients that were coming into the clinic and identify whatever their issues or deficiencies were on the exam room door with a yellow tag. Those days are gone. Now everything is in the EHR. You can systematically look at a patient’s record for the agents that are missing for their HF diagnosis. In addition, you can use best practice advisories that are electronically tagged to a patient’s record when you open their chart. These solutions are doable; the question is having the motivation to develop and implement them. Most institutions and healthcare systems will provide the IT infrastructure needed but having help from nurses or pharmacists is also doable.

There also are plenty of practical tools available to help improve patient care. These include position papers and guidelines from the American College of Cardiology (ACC), American Heart Association, and Heart Failure Society of America. For example, the ACC produces a series of resources that are expert consensus decision pathways. There are 3 of them dedicated to HFrEF, HFpEF, and acute HF. The beauty of these resources is that they are not evidence-based guidelines that discuss nuanced mechanisms of action. Rather, they identify practical guidance for treating HF and include checklists that can be used in your clinical practice.

In under-resourced and community-based settings, gaps in care are especially pronounced. Unfortunately, these are the settings where patients often present with more comorbidities and higher risk. Therefore, there is some risk for treatment mismatch as well. Having said that, we must strive to provide evidence-based therapy regardless of the setting. If that is simply not possible, then prescribing some therapy is better than no therapy. Furthermore, although smaller doses are not as good as using the recommended dose, smaller doses are still better than no doses at all. For those really struggling, you can always speak with your local pharmaceutical representatives and seek out other programs that help with vouchers and financial assistance. Many institutions and healthcare systems have community-based clinics to help address health equity. This is a big concern in healthcare in general, and a lot of people are working on it. Although it may not be ideal to utilize under-resourced clinics in this scenario, we are not entirely without solutions. If we can use these strategies, hopefully we can help provide our patients with better outcomes.

SGLT2 Inhibitors for HF
SGLT2 inhibitors offer huge benefits in treating HF. Historically, if you suspected HF, you had to wait on echocardiogram results to come back to confirm a diagnosis. Now we have a therapy that works across the ejection fraction spectrum, so we can start treatment early. SGLT2 inhibitors also offer benefits when taken alongside other therapies. For instance, they lower the risk of hyperkalemia with MRA use. Because of their diuretic effect, SGLT2 inhibitors may also counteract the initial negative inotropic congestive effects of beta-blockers. In many ways, HCPs can rely on SGLT2 inhibitors as a first-line therapy in HF because they can be used in almost all patients.

In addition, SGLT2 inhibitors are easy to use. With multiple indications, patients would take 1 dose daily with or without food without a need for titration.

A key issue with HF treatment is ensuring adherence. There are tools and resources available that patients can use before their visit to measure adherence. If you want to be more efficient and cannot provide a one-on-one, detailed education session, there are opportunities for patient groups to provide that education before their appointment. There are plenty of tools available that can be used for patient education and as reminders. There are some high-tech tools coming in the future that could allow prescription bottles to have reminder systems. In the meantime, patients can set up reminders through specific apps on their phones. But all of these things will continue to evolve.

Your Thoughts
How often are you prescribing SGLT2 inhibitors for your patients with HF? You can get involved in the conversation by answering the poll question or posting a comment below.

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