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The practice gap in heart failure—the elephant in the room

The recent publication of the 2016 European Society of Cardiology (ESC) Guidelines on the diagnosis and treatment of acute and chronic heart failure (HF)1 underlines the significant progress that has been made in the management of this syndrome in recent years. This very worthy publication outlines the many available and well-proven therapeutic options that are now available to effectively treat patients with HF, especially those with reduced ejection fraction. However, despite this good news story, there remains a fundamental challenge in HF not given detailed discussion in the recent guidelines: namely, what is the optimal structure from which to direct these important therapeutic options outlined in the guidelines? The ESC Guidelines do recognize the importance of this issue by giving the recommendation that HF patients should have access to multidisciplinary disease management programmes and encourage “a ‘seamless’ system of care that embraces both the community and hospital throughout the health care journey”. Previously, the ESC Heart Failure Association Committee published on standards for delivering HF care.2 However, as outlined by international data, there are major challenges in implementing this vision. These deficiencies stem predominantly, in our opinion, from one central fundamental problem: a lack of cohesive interaction between primary care, where HF care should be centred, and specialist cardiologist input for advice and involvement on aspects of management at critical phases of the life cycle of a HF patient. Emergency department visits and hospitalizations continue to remain the major expenditures in HF care3 and strategies to aid in community management of HF and optimization of therapeutic strategies are required. Unless we address this deficiency many patients with HF will never see the benefits of strategies outlined in the guideline document and the gap between guidelines and practice will remain an insurmountable challenge.