From Awareness to Implementation: Bridging Gaps in Heart Failure Care in Korea—Insights From KNOW-HF

Despite substantial advancements in pharmacologic and device-based therapies, heart failure (HF) continues to impose a major global burden of morbidity, mortality, and healthcare utilization.¹,²⁾ In Korea as well, the prevalence of HF and its associated socioeconomic burden are steadily increasing, driven by population aging and improved survival among patients with cardiovascular diseases.³⁾ Because early recognition and the timely initiation of evidence-based therapy are critical to improving outcomes, major efforts have been made to promote HF awareness and guideline-directed care. However, a significant gap persists between evidence-based recommendations and real-world clinical practice.⁴⁾ This disparity is often exacerbated by variations in HF awareness and practice patterns among physicians. The Study group on Heart Failure Awareness and Perception in Europe (SHAPE), highlighted this provider-level variability. Despite guidelines, non-cardiology physicians underused key diagnostics and cornerstone therapies, which was associated with lower adoption of recommended HF management strategies.⁵⁾

In this context, the nationwide questionnaire-based Korean Awareness of Heart Failure (KNOW-HF) survey by Lee et al.⁶⁾ provides a cross-sectional snapshot of physician awareness and practice patterns in Korea. In an online survey of 543 physicians (209 primary care physicians [PCPs] and 334 cardiology specialists) conducted in July–August 2019, a 23-item questionnaire assessed HF awareness, diagnostic testing practices, and guideline-directed medical therapy (GDMT) use. Although both PCPs and cardiology specialists correctly understood the core definition of HF, their perception of its lifetime risk, post-discharge mortality, and hospitalization-related economic burden remained suboptimal. Furthermore, consistent with SHAPE, the most pronounced gaps between the 2 groups were observed in 2 early steps—objective confirmation of HF and implementation of GDMT.⁵⁾

Moving beyond initial clinical assessment, contemporary guidelines recommend objective confirmation through echocardiography and natriuretic peptide testing to ensure an accurate HF diagnosis.⁷⁾ In this nationwide survey, cardiology specialists reported almost universal use of these tools, whereas PCPs used them substantially less often (echocardiography: 61% vs. 97% and natriuretic peptide: 57% vs. 90%), and nearly 30% reported diagnosing HF primarily on symptoms and signs without additional testing. Such diagnostic uncertainty can have downstream consequences, delaying phenotyping, disease-modifying therapy initiation, and consistent referral decisions. Importantly, lower testing rates in primary care may not indicate lack of awareness alone but also reflect system-level constraints, such as limited availability of point-of-care diagnostics, reliance on external referral for testing, and workflow-related barriers that impede timely confirmation in routine practice.

GDMT utilization reveals another major disparity between primary care and specialist settings. Cardiology specialists reported consistently higher use of renin-angiotensin system blockers, beta-blockers, and mineralocorticoid receptor antagonists compared with PCPs, a pattern reported globally.⁵,⁸⁾ However, even among specialists, the absolute uptake of these evidence-based therapies remains below ideal levels. More importantly, the survey clarifies why GDMT is not prescribed in routine practice. Safety and tolerability concerns—hypotension, renal dysfunction, and electrolyte imbalance—dominate in both groups, while PCPs more often cite older age as a reason. This “age barrier” likely extends beyond chronological age, reflecting concerns regarding frailty and multimorbidity, which exacerbate the risk of adverse effects and limit the capacity for frequent reassessment. These findings highlight the importance of pairing practical education on GDMT initiation and titration with feasible monitoring plans and follow-up pathways that fit routine practice. Furthermore, advanced HF therapies remain concentrated in hospital settings. Such concentration is expected, but it also underscores the importance of clear referral thresholds and shared-care agreements so that eligible patients are not missed.

Taken together, these findings support a shift from general awareness to implementation—combining role-specific education with system-level reforms. A structured education program should standardize key elements across the care pathway, including early suspicion criteria, objective diagnostic steps, referral triggers, and practical GDMT algorithms for initiation, titration, and safety monitoring. In parallel, policy and system changes are needed to ensure timely access to echocardiography and natriuretic peptide testing and to build monitoring infrastructure that supports safe dose optimization. Finally, consensus-based referral criteria and shared-care pathways with advanced HF centers are essential to ensure timely escalation to device therapy and evaluation for advanced treatments.

Some limitations affect the interpretation of this study. First, as a questionnaire-based, self-reported study, the findings may not fully reflect observed practice, and the predefined questions and options limit assessment of key clinical context—diagnostic stage, frailty/multimorbidity, and titration rationale—thereby risking an overly simplified interpretation. Second, because the survey was conducted in 2019, it precedes the widespread integration of the “four pillars” of GDMT including angiotensin receptor-neprilysin inhibitor and sodium–glucose cotransporter-2 inhibitors. Practice patterns may therefore have changed. KNOW-HF2 has recently been completed, and is expected to reassess physician awareness and practice patterns in the post–four-pillars era. Despite these limitations, the present survey represents one of the first nationwide, physician-level assessments of HF awareness and practice in Korea, offering a benchmark of where care falters and a clear starting point for targeted implementation efforts.