Background:
Chronic heart failure (HF) is frequently undertreated in primary care. Four-pillar guideline-directed medical therapy (GDMT)—renin–angiotensin system inhibitors (RASi), beta blockers (BB), mineralocorticoid receptor antagonists (MRAs), and sodium–glucose cotransporter 2 inhibitors (SGLT2i)—is recommended for HF with reduced ejection fraction (HFrEF), which accounts for approximately half of the cases. In women, HF with preserved ejection fraction is more prevalent, which may limit GDMT eligibility and complicate interpretation of treatment rates. Real-world sex- and age-related disparities in GDMT uptake in German primary care remain incompletely characterised.
Objective:
To describe HF prevalence and GDMT patterns and compare uptake and initiation between WATCH HF 1.0 (January 2021–June 2023) and WATCH HF 2.0 (July 2023–December 2024), focusing on sex- and age-related differences.
Methods:
Anonymised electronic medical records from 1,244 (WATCH HF 1.0) and 1,687 (WATCH HF 2.0) German primary care practices were analysed. Adults with at least one of the following were included: hypertension, diabetes, or cardiovascular disease (including HF). Routine data with at least one year of follow-up were assessed (mean 1.7 and 1.3 years, respectively). Outcomes were HF prevalence and use/initiation of GDMT components and diuretics, stratified by sex and age group (<65, 65–79, ≥80 years). Analyses were descriptive and unadjusted; ejection fraction data were unavailable.
Results:
In WATCH HF 1.0, 54,721 of 448,837 patients were diagnosed with HF (12.2%; 52.8% women; mean age 73.9 years) compared with 54,002 of 452,284 in WATCH HF 2.0 (11.9%; 50.5% women; mean age 74.1 years). SGLT2i use increased substantially (men 23.1% to 37.0%; women 13.1% to 25.3%), though rates remained lower in women. MRA use rose modestly (men 28.0% to 29.4%; women 20.4% to 21.8%). RASi and BB use was largely stable, with lower rates in women. Complete four-pillar GDMT improved but remained low (men 10.3% to 15.0%; women 4.8% to 8.0%). Across age groups, SGLT2i use rose in all strata (22–24% in WATCH HF 2.0), while complete four-pillar therapy was lowest in patients aged ≥80 years (6.8%). New initiations increased broadly: SGLT2i (men 11.1% to 26.7%; women 6.8% to 21.5%), RASi (men 26.6% to 33.3%; women 22.6% to 31.7%), MRAs (men 10.4% to 16.6%; women 8.1% to 13.2%), BB (men 18.8% to 30.4%; women 16.1% to 27.2%). Diuretics were more frequently initiated in women. Initiation of complete four-pillar therapy remained lowest in patients aged ≥80 years (2.4% to 8.9%).
Conclusion:
GDMT uptake for HF in German primary care is improving but remains low, with consistent disparities in women and patients aged ≥80 years. Lower GDMT rates in women may partly reflect higher HFpEF prevalence. These findings support systematic EF characterisation and targeted eligibility assessment, particularly in women and older adults, to ensure guideline-concordant therapy optimisation.
