Current state of medication treatment practice for heart failure with reduced ejection fraction among cardiologists in Japan: a survey on the relationship between satisfaction levels and adherence to guideline-directed medical therapy

Abstract

Background

The number of patients with heart failure is steadily increasing in parallel with the aging of the population in Japan. This study aimed to assess the level of satisfaction with the latest treatments, identify the factors influencing satisfaction, and investigate the current guideline-directed medical therapy (GDMT) practice for heart failure with reduced ejection fraction (HFrEF) among cardiologists in Japan.

Methods

Respondents were categorised into two groups based on their level of satisfaction with the current treatment for HFrEF. Those who responded “(1) Not satisfied,” “(2) Somewhat dissatisfied,” or “(3) Neither satisfied nor dissatisfied” encompassed the dissatisfied group. Conversely, those who responded “(4) Somewhat satisfied” or “(5) Satisfied” comprised the satisfied group.

Results

A total of 203 valid responses were collected from cardiologists in Japan in a survey conducted between December 27, 2023, and January 30, 2024. These respondents were divided into two groups based on their satisfaction with the current HFrEF treatment: those who were dissatisfied (n = 92) and those who were satisfied (n = 111). The demographics of the respondents in the two groups revealed no differences. However, the dissatisfied group reported a significantly higher proportion of patients under their care who were considered refractory to treatment than the satisfied group (p = 0.015). Although the dissatisfied group was more likely to indicate that patients’ heart failure (HF) underlying characteristics influenced their treatment more (4.15 vs. 3.90, p = 0.045), the satisfied group was significantly more likely to indicate that domestic (4.38 vs. 4.13, p = 0.021) and international (3.85 vs. 3.60, p = 0.039) guidelines influenced their HF treatment practices. Sodium–glucose transport protein 2 (SGLT2) inhibitor prescription related to increased satisfaction (odds ratio, 2.199; 95% confidence interval, 1.102–4.392; p = 0.025).

Conclusion

Approximately 50% of the respondents were dissatisfied with the current pharmacological treatment of patients with chronic HFrEF, suggesting that SGLT2 inhibitors were prescribed less frequently and that patient management tended to be guided more by individual symptoms and underlying HF characteristics rather than strict adherence to GDMT. The use of SGLT2 inhibitors was significantly associated with higher treatment satisfaction, particularly among physicians who adhered more closely to current GDMT recommendations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-025-05014-x.

Background

Japan has the longest life expectancy in the world, owing to a wholesome diet and innovative medical technology. As of 2022, 29.0% (36.24 million) of the population are aged ≥ 65 years, with 13.5% (16.87 million) aged 65–74 and 15.5% (19.36 million) aged ≥ 75. The country is experiencing population aging at an unprecedented global rate [1]. The number of patients with heart failure (HF) is increasing in conjunction with an aging population, and Japan has entered an era called the “HF pandemic.” HF is a leading cause of death from cardiovascular diseases in the country. It can result in recurrent hospitalisations, progressive deterioration, and a markedly high risk of sudden death [2–4]. The number of patients with heart failure (HF) has risen from 1 million in 2005 to 1.2 million in 2020, demonstrating a significant rise over the past 15 years [5]. Although no epidemiological data exist on the prevalence of HF by age in Japan [6], considering the high proportion of patients aged ≥ 65 years in the CHART-2 trial, this number is assumed to further increase in the future.

The development of drugs for managing HF, which affects up to 30 million patients worldwide [7], is rapidly progressing; in response to the accumulation of new evidence, the guidelines are frequently revised in Japan and other countries. The Japanese Society of Cardiology (JCS) and the Japanese Heart Failure Society (JHFS) developed a treatment algorithm for the pharmacological therapy of HF with reduced left ventricular ejection fraction (LVEF) (HFrEF) in the JCS/JHFS 2021 Guideline-Focused Update on Diagnosis and Treatment of Acute and Chronic Heart Failure [4]. It recommends that treatment in the chronic phase (stage C) should be determined on the basis of the LVEF: angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) as basic drugs for HFrEF, with the addition of beta-blockers, with maximum doses administered as long as they are well tolerated. Moreover, mineralocorticoid receptor antagonists (MRAs), which have renal and cardioprotective effects, are recommended as the initial treatment. The introduction of angiotensin receptor neprilysin inhibitors (ARNIs) instead of ACE inhibitors/ARBs represents another option. Furthermore, the introduction of sodium–glucose co-transporter 2 (SGLT2) inhibitors in patients with or without diabetes may be considered on the basis of preventing a combined event of worsening HF and cardiovascular death. Diuretics aimed at improving symptoms are administered as appropriate. Ivabradine therapy initiation is recommended when the patient is symptomatic and has a sinus rhythm and heart rate of > 75 beats/min despite using basic therapies [4]. Despite the development of current evidence-based therapies, it is uncertain whether the novel pharmacotherapies available in Japan improve prescribers’ satisfaction with treatment.

Therefore, this study aimed to assess cardiologists’ satisfaction with current HFrEF treatments in Japan, identify factors influencing satisfaction, and investigate adherence to guideline-directed medical therapy (GDMT) in clinical practice.

Materials and methods

Study participants

This study specifically focused on the current pharmacological treatment practices for HFrEF using the online survey system of TCROSS NEWS, Japan’s largest news website specializing in cardiology. Since its launch in January 2010, TCROSS NEWS has served as a highly specialized platform, with approximately 90% (~ 7,000) of its physician members being cardiologists. Previous studies have described the characteristics and reliability of the platform [8, 9]. In brief, according to the Japanese Circulation Society, there are 17,260 board-certified cardiologists in Japan (as of March 2024), including private practitioners and hospital-based physicians. In parallel, the Japanese Association of Cardiovascular Intervention and Therapeutics, which mainly comprises practicing interventional cardiologists and other clinically active specialists, has approximately 9,000 members (as of August 2024). Thus, the membership of TCROSS NEWS represents approximately 78% of this core professional group.

For this study, we targeted approximately 3,500 board-certified cardiologists who agreed to receive the TCROSS NEWS email newsletter. Based on the estimated total population of cardiologists in Japan and assuming a 95% confidence level with a 7% margin of error, we calculated that a minimum sample size of 194 individuals would be required. We set a recruitment target of 210 participants, taking into account a potential 5% rate of invalid or incomplete responses.

Survey items

Ten survey categories with 38 questions, encompassing respondents’ demographics, proportion of in- and out-patients with HFrEF, proportion of patients with refractory HF, proportion of HFrEF medications available in Japan, satisfaction with existing treatments, and patient background (defined as personal and evidence-based factors influencing prescription), were analyzed.

Respondents’ demographic-related questions included the type of affiliation, sex, age distribution, and area of expertise. They were asked to indicate their age category on an 8-point scale ranging from 24 to ≥ 61 years. Respondents were asked to select their specialty area within cardiology, such as ischemia, HF, arrhythmia, structural heart disease, ultrasonography, general cardiology, emergency medicine, or others. The proportions of HF and refractory HFrEF in in- and out-patient care were assessed on 6- and 8-point scales, respectively. The survey questions are included in the “survey form” in the appendix. To improve interpretability, the most influential survey items included physicians’ self-rated satisfaction with current HFrEF pharmacological treatment, factors influencing prescription decisions, and the prescription frequency of each medication class such as ACEi/ARB, ARNI, MRA, and SGLT2 inhibitors. These key variables were used in the main analysis and logistic regression.

When setting the treatment options (percentages) for each medication, a preliminary survey conducted in March 2023 was used as the reference point. In the preliminary survey, using a 6-point scale, respondents were asked to select whether the target therapeutic agent was “never used,” “used in very few cases,” “used in approximately 20% of cases,” “used in approximately 50% of cases,” “used in approximately 70% of cases,” and “used in approximately all cases.” However, a variation in prescription rates was observed among the therapeutic agents specified in the GDMT (ACEi/ARB, ARNI, SGLT2, and MRA) and other treatments, resulting in a wider range of alternatives in the survey from “never used” to “used in all cases” (Appendix). In brief, an 8-point scale ranging from 0 to 7 was used in the main survey to quantify the prescription frequency of each medication. The scale corresponded to the following categories: “none” (0), “ < 4%” (1), “5–9%” (2), “10–24%” (3), “25–49%” (4), “50–74%” (5), “ ≥ 75%” (6), and “all patients” (7). These categories were used to calculate the mean prescription scores presented in Fig. 1.

Fig. 1.

Prescribing scores in the available drugs in treating patients with HFrEF

Definitions

In real-world clinical practice, refractory HFrEF is challenging to manage. Furthermore, respondents who selected “(1) Not satisfied,” “(2) Somewhat dissatisfied,” or “(3) Neither satisfied nor dissatisfied” based on responses to the question: “How satisfied are you with existing heart failure treatments for HFrEF?” (Appendix, question 7–2) were categorized as the dissatisfied group. Conversely, those who responded “(4) Somewhat satisfied” and “(5) Satisfied” comprised the satisfied group. This classification was determined using the median value of the responses, which was 4.0 in this study. Therefore, responses with a value of ≥ 4.0 were classified as satisfied, whereas those < 4.0 were classified as dissatisfied.

Statistical analysis

Continuous variables were compared using Student’s t-test, whereas categorical variables were expressed as frequencies with percentages and compared using the chi-square test. When the expected cell count in any contingency table was < 5, Fisher’s exact test was applied instead. Personal and evidence-based factors influencing prescription and individual medications were set as explanatory variables. To identify the causes of the dichotomous satisfaction with the existing treatment (dissatisfied and satisfied groups), odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression analysis. Statistical significance was set at p < 0.05. Analyses were performed using the Statistical Package for the Social Sciences version 28.0 (IBM Corporation, Armonk, NY, USA).

Ethics approval and consent to participate

This study was approved by the Ethics Committee of TCROSS Co., Ltd. (Approval No. 2023–006; date of approval: December 21, 2023). Informed consent was obtained from all participants prior to their inclusion in the study. The study was conducted using an anonymous web-based survey. Participants were informed about the purpose of the study, data handling, and confidentiality. The authors had no access to identifying information, and responses were statistically processed to ensure anonymity.

Results

Between December 27, 2023, and January 30, 2024, 213 cardiologists who had consented to receive the TCROSS NEWS e-newsletter responded to the survey. After excluding invalid or incomplete responses, 203 valid responses were obtained, meeting the initial recruitment target of 210 participants. The dissatisfied group (1–3 points) comprised 92 respondents (45.3%), and the satisfied group (4 and 5 points) comprised 111 respondents (54.7%).

Sex, age distribution, institution type, specialty area, and the proportion of patients with refractory HFrEF managed by the respondents were compared between the two groups (Table 1). The demographics of the respondents in the two groups showed no differences. However, the dissatisfied group demonstrated a significantly higher proportion of patients under their care who were considered refractory to treatment than the satisfied group (p = 0.015).

Table 1.

Respondents’ attribute and proportion of refractory patients

	Total (n = 203)	Dissatisfied (n = 92)	Satisfied (n = 111)	p-value
Sex				0.452
Male	185 (91.1%)	85 (92.4%)	100 (90.1%)
Female	17 (8.4%)	6 (6.5%)	11 (9.9%)
Age category				0.188
less than 30	11 (5.4%)	8 (8.7%)	3 (2.7%)
31–40	76 (37.4%)	28 (30.4%)	48 (43.2%)
41–50	64 (31.5%)	30 (32.6%)	34 (30.6%)
51–60	37 (18.2%)	18 (19.6%)	19 (17.1%)
more than 61	15 (7.4%)	8 (8.7%)	7 (6.3%)
Respondents’ affiliation				0.55
HP without bed	8 (3.9%)	5 (5.4%)	3 (2.7%)
Cardiovascular center	16 (7.9%)	9 (9.8%)	7 (6.3%)
General HP	138 (68.0%)	59 (64.1%)	79 (71.2%)
University HP	41 (20.2%)	19 (20.7%)	22 (19.8%)
Sub-speciality				0.426
Cardiologist (IHD)	96 (47.3%)	39 (42.4%)	57 (51.4%)
Cardiologist (HF)	31 (15.3%)	14 (15.2%)	17 (15.3%)
Cardiologist (Arrthymia)	10 (4.9%)	7 (7.6%)	3 (2.7%)
Cardiologist (SHD)	13 (6.4%)	6 (6.5%)	7 (6.3%)
Cardiologist (Echo)	1 (0.5%)	0 (0)	1 (0.9%)
General cardiology	45 (22.2%)	21 (22.8%)	24 (21.6%)
Acute care	2 (1.0%)	2 (2.2%)	0 (0)
Others	5 (2.5%)	3 (3.3%)	2 (1.8%)
Refractory patients				0.015
none	3 (1.5%)	1 (1.1%)	2 (1.8%)
< 5%	24 (11.8%)	5 (5.4%)	19 (17.1%)
5–9%	35 (17.2%)	14 (15.2%)	21 (18.9%)
10–19%	62 (30.5%)	28 (30.4%)	34 (30.6%)
20–29%	46 (22.7%)	20 (21.7%)	26 (23.4%)
30–39%	24 (11.8%)	17 (18.5%)	7 (6.3%)
40–49%	3 (1.5%)	3 (3.3%)	0 (0)
> 50%	6 (3.0%)	4 (4.3%)	2 (1.8%)

Echo Echocardiography, HF Heart failure, HP Hospital, IHD Ischemic heart disease, SHD Structural heart disease

The dissatisfied group was more likely to indicate that patients’ underlying HF characteristics influenced their treatment more than the satisfied group (4.15 vs. 3.90, p = 0.045), whereas the satisfied group was significantly more likely to indicate that domestic (4.38 vs. 4.13, p = 0.021) and international (3.85 vs. 3.60, p = 0.039) guidelines influenced HFrEF treatment practice (Table 2).

Table 2.

Personal and evidence-based factors that affect treatment choice for HFrEF

Factors	Variables	Dissatisfied (n = 92)	Satisfied (n = 111)	p-value
Personal Factors	Underlying HF characteristics	4.15	3.90	0.045
	Sex	2.37	2.23	0.284
	Age	3.71	3.59	0.368
	Left ventricular ejection fraction	4.01	3.88	0.347
	Renal function	4.15	4.25	0.357
	Hypertension	4.21	4.23	0.862
	Pulse	3.98	3.94	0.732
	Drug price	3.07	2.94	0.327
	Patient economic condition	3.26	3.18	0.517
	Drug compliance	3.55	3.56	0.973
	Frequency of HF hospitalization	4.03	4.01	0.848
	Nonsustained ventricular tachycardia	3.83	3.72	0.442
Evidence –based Factors	The Japanese guidelines	4.13	4.38	0.021
	The US and EU guidelines	3.60	3.85	0.039
	Outcomes of clinical trials	3.7	3.92	0.052
	Information for Use	3.48	3.58	0.476
	Superiors/peers	3.22	3.03	0.147
	Opinions of thought leaders	3.35	3.36	0.914
	Sales/medical representatives	2.75	2.86	0.337
	Academic conferences	3.38	3.56	0.094
	Sponsored web-symposium	3.07	3.08	0.89
	News site	2.96	3.03	0.554
	Corporate web-site	2.75	2.82	0.569

1 point = not affected, 2 point = almost affected, 3 point = often affected, 4 point = almost affected, 5 point = affected

HFrEF Heart failure with reduced ejection fraction, EU European Union, HF Heart failure, US United States

Furthermore, the mean prescribing scores of the target treatments in the dissatisfied and satisfied groups were compared. Accordingly, the dissatisfied group was significantly less likely to prescribe SGLT2 inhibitors than the satisfied group (5.95 vs. 6.47, p = 0.006). Although the difference was not statistically significant, the dissatisfied group tended to exhibit a lower score of ARNI prescriptions than the satisfied group (5.35 vs. 5.64, p = 0.091). The prescription scores for other medications were comparable between the two groups (Fig. 1).

Factors influencing the satisfaction with the current treatment of patients with HFrEF were assessed using logistic regression analysis, with personal and evidence-based factors influencing prescription and the choice of each medication as explanatory variables (Table 3). Underlying HF characteristics (OR, 0.542; 95% CI, 0.317–0.927; p = 0.025), supervisor/peer recommendation (OR, 0.335; 95% CI, 0.167–0.672; p = 0.002), and MRA use (OR, 0.459; 95% CI, 0.235–0.896; p = 0.022) reduced the satisfaction levels, whereas the use of SGLT2 inhibitors contributed to increased satisfaction levels (OR, 2.199; 95% CI, 1.102–4.392; p = 0.025) in the treatment of patients with HFrEF.

Table 3.

Factors affecting the satisfied and dissatisfied respondents

		OR	95% CI		p-value
			Lower	Upper
Personal factors	Underlying HF characteristics	0.542	0.317	0.926	0.025
	Sex	1.058	0.691	1.621	0.795
	Age	1.202	0.714	2.026	0.489
	Left ventricular ejection fraction	0.756	0.451	1.267	0.288
	Renal function	1.624	0.74	3.564	0.226
	Hypertension	1.568	0.639	3.849	0.326
	Pulse	0.696	0.354	1.372	0.296
	Drug price	0.846	0.477	1.501	0.567
	Patient economic condition	0.842	0.461	1.535	0.574
	Drug compliance	1.015	0.591	1.74	0.958
	Frequency of HF hospitalization	1.251	0.706	2.218	0.442
	Nonsustained ventricular tachycardia	0.784	0.481	1.278	0.33
Evidence-based factors	The Japanese guidelines	1.587	0.911	2.767	0.103
	The US and EU guidelines	1.287	0.768	2.155	0.338
	Outcomes of clinical trials	1.048	0.593	1.85	0.873
	Information for Use	1.1	0.705	1.717	0.674
	Superiors/peers	0.335	0.167	0.672	0.002
	Opinions of thought leaders	1.668	0.785	3.543	0.183
	Sales/medical representatives	1.512	0.765	2.988	0.234
	Academic conferences	1.375	0.703	2.689	0.352
	Sponsored web-symposium	0.523	0.216	1.266	0.151
	News site	1.094	0.474	2.523	0.833
	Corporate web-site	1.392	0.657	2.948	0.388
Medication factors	Prportion of ACEi-ARB use	1.32	0.799	2.18	0.278
	Prportion of MRA use	0.459	0.235	0.896	0.022
	Proportion of beta brocker use	1.098	0.546	2.209	0.793
	Proportion of ARNI use	1.851	0.915	3.743	0.087
	Proportion of SGLT2-i use	2.199	1.102	4.392	0.025
	Proportion of ivabradine use	1.343	0.711	2.538	0.363
	Proportion of tolvaptan use	1.029	0.613	1.728	0.914
	Proportion of beluiciguat use	0.574	0.326	1.011	0.054
	Proportion of pimobendan use	0.736	0.384	1.411	0.355

ACEi Angiotensin-converting enzyme inhibitor, ARB Angiotensin II receptor blocker, ARNI Angiotensin receptor neprilysin inhibitor, HF Heart failure, MRA Mineralocorticoid receptor antagonist, SGLT2-i Sodium-Glucose co-Transporter-2 Inhibitor

Discussion

This study involving cardiology specialists found that (1) the satisfaction with current treatment practices was lower among respondents who treated a higher proportion of patients with refractory HFrEF and were more focused on patients with an underlying HF characteristic, whereas those who were satisfied with current treatment practices were more influenced by domestic and international guidelines. (2) The dissatisfied group was less likely to prescribe SGLT2 inhibitors, suggesting a possible association between SGLT2 inhibitor use and treatment satisfaction.

As specified in the JCS/JHFS 2021 Guideline-Focused Update on Diagnosis and Treatment of Acute and Chronic Heart Failure [4], pharmacotherapy for HFrEF is evolving daily, and treatment approaches are updated as new evidence emerges. In Japan, the revision of the JCS 2017/JHFS 2017 Guideline on Diagnosis and Treatment of Acute and Chronic HF to the current version took 4 years. As the guidelines are revised on the basis of the latest evidence, adherence to them causes an improved prognosis. However, evidence-based medicine is often not adequately implemented in real-world clinical practice. The CHAMP-HF registry reported that even classical cardioprotective agents were not prescribed in approximately 30% of patients for whom they were indicated and that even when they were prescribed, approximately 50% of the patients received inadequate doses [10]. Previous studies have shown that patients treated in accordance with guidelines exhibit better prognoses [11]; however, the finding that GDMT is not adhered to is observed not only in Europe and the USA, but also in Japan. Eliminating clinical inertia is the most significant; however, individual patient limitations for GDMT, including renal dysfunction, bradycardia, and comorbidities, typically exist. Thus, GDMT underuse seems to be independent of patient eligibility for these medications in the guidelines [12].

Considering that underlying HF conditions influenced treatment more than the guidelines in the dissatisfied group compared with that in the satisfied group, nonadherence to GDMT would make HFrEF management more challenging, as reflected in the dissatisfaction with existing treatments.

The results of this study indicated that the dissatisfied group was less likely to prescribe SGLT2 inhibitors than the satisfied group. Despite the large body of evidence accumulated to date regarding the use of SGLT2 inhibitors against HFrEF [13–19], the prescription of these agents was significantly associated with higher treatment satisfaction in this study. This association suggests a potential link between the use of SGLT2 inhibitors and physician satisfaction. However, given the cross-sectional observational design of the study, this finding should be interpreted as an association rather than a causal relationship.

In Japan, empirical studies on drug prescription practices are limited. The survey conducted by Watanabe et al. involving 287 doctors revealed that the factor that most influenced prescription was “own treatment experience,” whereas the influence of “experience gained from senior doctors” and “prescription from a previous doctor” were in the middle of the overall ranking, being 9th and 7th of 14 items [20]. In a review of 36 studies, McGettigan et al. reported that “physician attributes” strongly influenced prescription decisions. In this review, “physician experience,” “expertise,” and “continuous development of the area of interest of the physician” were the attributes that had a particularly strong influence on prescription. Several studies in this review emphasized the influence of clinical experience on prescription, with studies indicating that doctors tend to prescribe drugs that they are familiar with and have experienced successful patient treatment in the past [21].

In this study, the respondents included cardiologists, several of whom had accumulated experience and undeniably used their criteria for decision-making while prescribing. Although doctors generally adhere to hospital guidelines and policies that align with their views [22], some expressed resistance to standards that restrict their professional autonomy [23]. While recognizing the theoretical significance of medical reference books and scientific literature [24], information from supervisors, colleagues, and other sources that they trust is an essential factor when making prescription decisions. This study revealed that the prescription of SGLT2 inhibitors, which has been added to the guidelines for acute and chronic HF management, was higher in the satisfied group but lower in the dissatisfied group. Moreover, the findings suggested that approximately 50% of the respondents trusted their experience and sources rather than treatment in adherence to rapidly changing guidelines in Japan.

Interestingly, MRA prescription was inversely associated with higher satisfaction in our model. One possible explanation is that physicians treating more clinically complex patients—who often require MRA due to persistent congestion or advanced HFrEF—may experience therapeutic frustration or perceive limited incremental benefits from established therapies [25]. Additionally, MRA use might be more common in patients with resistant hypertension, chronic kidney disease, or hypotension, which complicate overall treatment satisfaction [26]. Another possibility is prescribing fatigue or burden associated with polypharmacy, where the need to add MRAs may reflect challenges in achieving optimal outcomes despite guideline adherence.

This study had several limitations. First, the sample size was limited to 203 respondents, and the results could not be definitively considered on the basis of the actual population. Second, the findings were based on the observations of cardiologists in Japan and could not be considered the same in other countries, where available drugs and dosage specifications may vary from those in Japan. Third, the survey employed ordinal scales, which were treated as continuous variables in the statistical analyses. Although this strategy is extensively employed in survey-based research, it assumes equal intervals between score levels, which may not accurately represent real-world clinical differences. This limitation should be considered when interpreting the comparative and regression results. Fourth, satisfaction scores were dichotomised using a median split, a common approach in the absence of established thresholds. While this method may oversimplify nuances near the cut-off point, it was deemed appropriate given the exploratory nature of the study and the absence of validated anchor-based classifications for treatment satisfaction in HFrEF. Despite this limitation, median split remains a widely used and pragmatic approach in similar survey-based research settings. Moreover, this study did not provide adequate insight into patient outcomes, including all-cause and cardiovascular mortality, which are crucial within the realm of HF management. Additionally, the study lacked sufficient data on cardiologists’ satisfaction levels with existing medical practices. Although the association between institutional affiliation and satisfaction was evaluated using the chi-square test, we acknowledge that some expected cell counts were likely below 5. Fisher’s exact test, which is preferred in such cases, was not applicable owing to the presence of more than two categories. Furthermore, because the participants were recruited through TCROSS NEWS, which targets a highly specialised group of cardiologists, the results may not be representative of the broader physician population, including general practitioners, cardiologists not engaged with digital platforms, or those practicing in rural or non-tertiary care settings. Finally, although not assessed in this study, institutional factors such as formulary restrictions and titration protocols may also influence prescription behaviours and warrant further investigation.

Conclusions

This study on cardiologists in Japan revealed that approximately 50% of the respondents were not satisfied with the current pharmacological treatment of patients with HFrEF, indicating that they rarely prescribe SGLT2 inhibitors and tailor treatment to patients’ symptoms and underlying HF characteristics rather than adhering to GDMT.

In addition to the underuse of SGLT2 inhibitors, other factors such as administrative constraints, patient comorbidities, and limited institutional support for medication up-titration may also contribute to dissatisfaction with current HFrEF treatment strategies. These findings should be interpreted with caution, as the study was limited to cardiologists in Japan and may not reflect broader prescribing behaviours in general medicine or among non-cardiologist physicians.

Although this study did not evaluate patient-level outcomes, the observed association between physician satisfaction and adherence to guideline-directed medical therapy may have implications for patient prognosis. Further research is warranted to explore this potential link.

Abbreviations

ACE

Angiotensin-converting enzyme

ARB

Angiotensin II receptor blockers

ARNI

Angiotensin receptor neprilysin inhibitor

CI

Confidence interval

EF

Ejection fraction

GDMT

Guideline-directed medical therapy

HF

Heart failure

HFrEF

Reduced left ventricular ejection fraction

JCS

Japanese Society of Cardiology

JHFS

Japanese Heart Failure Society

LVEF

Left ventricular ejection fraction

MRA

Mineralocorticoid receptor antagonist

OR

Odds ratio

SGLT2

Sodium–glucose co-transporter 2

Authors’ contributions

S.H. created the concept, research, design, statistical analysis, and wrote the main manuscript. Y.M. contributed to acquire and interpret the data. T.M. was responsible for the final approval of the article to be submitted. All authors reviewed the manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study was approved by the ethical board of TCROSS. Co., Ltd. (Approval Number 2023–006). Informed consent was obtained during the answering and submission of the web-based questionnaire. The study was conducted in accordance with the Helsinki Declaration.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.