Overview of findings from the UK and Ireland National Advanced Heart Failure Audit 2024

Abstract

Background

Approximately one million individuals live with heart failure in the UK, and clinicians diagnose around 200 000 new cases each year. Although lifesaving treatments such as heart transplantation (HTx) and left ventricular assist device (LVAD) therapy exist, healthcare providers perform only about 325 of these procedures annually across the UK and Ireland. This gap suggests that many eligible patients do not receive appropriate referrals for HTx or LVAD.

Aims

The Transplant Cardiology Working Group conducted the inaugural UK and Ireland National Advanced Heart Failure Audit Report 2024 to promote quality improvement in caring for patients with advanced heart failure (AHF). This first international multicentre audit specifically examined referral patterns for HTx and LVAD therapies to the seven adult heart transplant centres across the UK and Ireland.

Results

The audit identified approximately 100 referrals per month for transplant or LVAD assessment. Adjusting for age eligibility, referral rates varied significantly by region, with some areas showing high referral levels and others substantially lower. The audit also found that a considerable number of referred patients had contraindications to HTx or LVAD therapy. Importantly, neither distance to the nearest transplant centre nor the deprivation level of the patient’s postcode influenced referral likelihood, indicating that factors such as clinician awareness or local referral culture may drive variation. Additionally, women remain under-referred, comprising only one in three patients assessed for AHF therapies.

Conclusion

This audit provides the first concrete evidence of widespread potential inequity in access to AHF therapies across the UK and Ireland. These findings have important implications for national healthcare planning, including workforce development and allocation of public health resources. Further work is required to investigate barriers to referral, enhance clinician awareness and optimise care pathways for patients in need of both life-prolonging and supportive therapies.

WHAT IS ALREADY KNOWN ON THIS TOPIC.

WHAT THIS STUDY ADDS

• This first national audit demonstrates notable regional variation in referral rates for transplant and LVAD assessment, independent of socioeconomic deprivation or distance from a transplant centre, and shows that women represent only one-third of referrals.

• A high proportion of referred patients have potentially reversible contraindications, indicating missed opportunities for earlier optimisation before referral.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• These findings support national standardisation of referral pathways, investment in services that optimise patients with reversible contraindications, and policy initiatives aimed at improving equitable access to AHF therapies across the UK and Ireland.

Introduction

Heart failure (HF) affects over one million people in the UK and Ireland, with around 200 000 new diagnoses each year.¹ Despite advances in guideline-directed medical therapy (GDMT), median survival remains approximately 5 years, comparable to many malignancies. A subset of HF patients progresses to advanced heart failure (AHF), characterised by persistent symptoms and poor quality of life despite optimal treatment. Patients meeting the 2018 European Society of Cardiology (ESC) or American Heart Association criteria for AHF have a 1-year mortality of 21.5–50%.^{2 3}

Estimates of the number of patients in need of AHF therapies in the UK and Ireland can be informed by data from the National Heart Failure Audit and population-based epidemiological studies conducted in North America.^{3 4} There are 60 000–70 000 HF-related hospitalisations annually across England and Wales, with up to 30% of patients dying within a year of discharge.⁴ Although most admissions involve individuals aged ≥75 years, many of whom are unlikely to be able to tolerate or benefit from heart transplantation (HTx) or left ventricular assist device (LVAD) therapy, there remains a substantial subgroup of potentially eligible patients. Specifically, around 8000 patients (12.5%) are aged 18–64 years and therefore more likely to be suitable candidates for advanced therapies. Within this group, between 15–18.5% are expected to die within 1 year of discharge from hospital, indicating a significant population that may benefit from timely referral for HTx or LVAD evaluation (see figure 1).⁵ Based on international prevalence estimates,³ up to 50 000 patients are below the age of 65 years living with AHF in the UK. Even assuming a small proportion of these patients are eligible for advanced therapies, currently only around 300 patients (<1%) receive a HTx or LVAD each year in the UK, highlighting a substantial unmet need. ⁶ Meanwhile, a national study in Ireland on AHF prevalence found that approximately 5% of all patients attending routine outpatient HF clinics, and two-thirds of a pre-selected cohort of HF patients with reduced ejection fraction aged under 65, exhibited at least one biochemical or clinical marker indicative of AHF.⁷

Figure 1. Number of patients <65 years with 1 year follow-up and the post-admission mortality of heart patients aged between 18 and 65 years. Data from NICOR National Heart Failure Audit.⁵.

Access to HTx/LVAD is contingent on timely referral to one of seven UK and Ireland transplant centres. It remains unclear what proportion of eligible patients are referred and whether access varies by geography, socioeconomic status, gender, ethnicity or age. Referral appropriateness has also not been systematically evaluated.

To address these gaps, the Transplant cardiology working group (TCWG), comprising consultant cardiologists from all HTx centres across the Republic of Ireland and the four nations of the UK (England, Scotland, Wales and Northern Ireland), has initiated a national evaluation of referrals over a 4-month period.

Methods

Study aims

This study aims to assess referral patterns, equity of access and appropriateness of referrals for advanced HF therapies. The TCWG comprised consultant cardiologists from all of the UK and Ireland HTx centres (JP, JD, AM, SS, PC, CS, SL, SB, SP, EJ, OD), who coordinated this multicentre retrospective audit. Clinical governance and data-sharing approvals were obtained at each site.

Data were collected on all inpatient and outpatient referrals made to AHF units from 1 January 2024 to 30 April 2024.

Definitions

Outpatient referrals were defined as any patient referred for HTx or LVAD assessment with a formal outpatient referral (via letter, email, or electronic system). Inpatient referrals were defined as any inpatient transfer for assessment.

Patients were classified as having possible AHF if they met at least one ‘I NEED HELP’ criterion, including: (1) New York Heart Association (NYHA) class III–IV symptoms; (2) N-terminal-pro-brain natriuretic peptide (NT-proBNP) >1000 pg/mL; (3) end-organ dysfunction (eg, estimated glomerular filtration rate <60 mL/min/1.73 m², transaminases >3× upper limit of normal, or pulmonary artery systolic pressure >50 mm Hg); (4) left ventricular ejection fraction (LVEF) <30%; (5) appropriate implantable cardioverter defibrillator (ICD) shocks or recent ventricular arrhythmia; (6) persistent fluid overload despite optimal therapy; (7) escalating diuretic requirements; and (8) inability to tolerate, or need to down-titrate, GDMT.

Collected data included: referrer postcode (to generate heatmaps of referral sources); patient demographics (age, gender, height, weight, ethnicity); clinical data (NYHA class, NT-proBNP, creatinine, liver enzymes, pulmonary artery systolic pressure, LVEF, ICD history, recent hospitalisations, hypotension, GDMT intolerance); and potential contraindications to HTx/LVAD (eg, poor compliance, end-organ complications of diabetes, obesity, active substance/alcohol abuse). This dataset allowed the evaluation of referral volumes, appropriateness, and demographic and regional disparities in access to advanced HF therapies.

Ethical considerations, funding, transparency, patient and public involvement

Each participating site obtained local institutional approval to conduct this national audit. Data sharing agreements were established, with Harefield Hospital designated as the hosting organisation for data collation and analysis. Patient confidentiality was maintained in accordance with the NHS Confidentiality Policy (2014), and with the general data protection regulation (GDPR) principles of Ireland as appropriate. All data were anonymised before analysis. No identifiable patient information was shared between centres. As a retrospective audit of existing clinical practice, formal ethical approval was not required under NHS Health Research Authority guidelines.

This study received funding from the Royal Brompton and Harefield Hospitals Charity.

Patients and members of the public were not involved in the design, conduct, reporting or dissemination of this research.

Statistical analysis

Baseline characteristics are reported as frequencies and percentages for categorical variables, and as means with SD or medians with IQRs, depending on the distribution of continuous variables. Normality was assessed visually and with appropriate statistical tests.

Data sources

Index of Multiple Deprivation (IMD) scores for all postcodes in England were obtained from the English Indices of Deprivation 2019, published by the Ministry of Housing, Communities and Local Government. These data provide both an overall IMD score and rank for each postcode.⁸

Postcode data, including mappings between full postcodes and postcode areas, were obtained from the Ordnance Survey Code-Point Open dataset.⁹ This dataset includes geographic coordinates for each unit postcode in Great Britain, along with administrative and statistical area codes. Postcode areas were derived from the outward code of each postcode (ie, the alphabetical prefix, such as ‘LS’ from ‘LS12 3AB’).

Population estimates by age category for postcode areas in England and Wales were obtained from the 2011 Census using the publicly available Nomis data portal.¹⁰ Specifically, we used table LC1117EW – Sex by age, which provides census counts of usual residents by single year of age (up to age 24) and 5-year age bands (from age 25 onwards).

We extracted population counts for each postcode area by selecting the appropriate geography level within Nomis. Age categories were grouped to reflect individuals aged 16 to 69 years, by selecting single-year ages (16–24) and 5-year bands (25–29 through 65–69). Data were downloaded in comma-separated values format and aggregated as required for analysis.

Data processing and aggregation

To assess geographic access to transplant services, we calculated the road travel distance and estimated travel time from the centroid of each postcode area in the UK to the nearest transplant centre.

Centroid coordinates for postcode areas were obtained from the Ordnance Survey. The postcode locations of all UK heart transplant centres were identified and used. Using Google Maps, we computed both the road travel distance (in km) and the estimated travel time (in min) between each postcode area centroid and the nearest transplant centre. Travel time estimates were based on typical weekday driving conditions after 9:00 am, to avoid peak rush hour traffic but still reflect routine travel conditions.

The minimum travel distance and time for each postcode area (ie, to the nearest transplant centre) were retained, and summary statistics (eg, mean, median) were calculated across all areas.

For each postcode area, we calculated the median IMD score by averaging the IMD scores of all postcodes assigned to that postcode area. This provided an unweighted average level of deprivation for each postcode area. No population weighting was applied, meaning each postcode area contributed equally to the area-level average.

To visualise referral distribution, a heatmap was generated by grouping referrals according to the postcode area of the referring centre (eg, ‘LS’, ‘BS’, ‘SW’). Referral regions were stratified into quartiles based on the number of referrals per million population—red: <3 referrals/million; orange: 3–6 referrals/million; yellow: 6–9 referrals/million; green: >9 referrals/million.

For IMD analysis, the unit of analysis was postcode area. IMD data were analysed for 97 postcode areas in England.

Referral rate was measured as the number of referrals per million population ages 16 to 69 (ie, transplant eligible ages). Distance from a transplant centre was measured as the time in hours from the centroid of the postcode area to the nearest transplant centre. Deprivation was measured using the median of the IMD across the postcode area.

Sensitivity analyses using distance in km from the postcode area centroid to the nearest transplant centre, and/or mean IMD ranking for the postcode area, were performed; in all cases, similar results were found.

A series of count models were tested to estimate the relationship between referrals and the covariates driving distance and median IMD rank. All models were controlled for the age-eligible population in each postcode area by including exposure in the model, that is, the natural log of the population with the coefficient fixed to 1. For all models shown, negative binomial regression models fit significantly better (p<0.05) than the corresponding Poisson regression models. Negative binomial models significantly improve model fit when the conditional dispersion is greater than the conditional mean.

Results

Participant characteristics

A total of 416 patients were referred for HTx or LVAD assessment across the seven transplant centres in the UK and Ireland between January and April 2024 (see table 1). The median age was 52 years, 67% were male, and 27% were of minority ethnic / global majority background. The underlying aetiology of HF was non-ischaemic in 55%, ischaemic in 29%, and hypertrophic or restrictive cardiomyopathy in 7%. A small proportion (3%) had adult congenital heart disease. Referrals were relatively evenly split between outpatients (56%) and inpatient interhospital transfers (44%).

Table 1. Characteristics and outcomes of advanced heart failure referrals to transplant centres across UK and Ireland between January 2024 and April 2024.

Characteristics		Total N (%)
Total patients recruited		416
Ethnicity (white)		302 (73%)
Male		279 (67%)
Median age (years, IQR)		52 (41–59)
Aetiology
Ischaemic		122 (29%)
Non-ischaemic		227 (55%)
Adult congenital heart disease		11 (3%)
Hypertrophic or restrictive cardiomyopathy		29 (7%)
Characteristics of outpatient referral cohort		Total N (%)
Total number of outpatient referrals		234 (56%)
No GDMT		3 (1.3%)
β-blocker		198 (84.6%)
RAAS blockade		194 (82.9%)
Aldosterone antagonist		189 (80.8%)
SGLT2 inhibitor		173 (73.9%)
I NEED HELP criteria
Inotropes		Nil
NYHA class III/ IV		151 (65%)
Elevated NT-proBNP		125 (53%)
Renal or liver dysfunction		56 (24%)
LVEF <30%		151 (65%)
Appropriate ICD shock or ventricular tachyarrhythmias		45 (19%)
More than one heart failure hospitalisation or unplanned clinic visit		85 (36%)
Fluid overload or increasing diuretic dose		61 (26%)
Systolic blood pressure <90 mm Hg		12 (5%)
Inability to up-titrate GDMT or reduction in GDMT		42 (18%)
Outcomes of outpatient referrals		Total N (%)
Too well		102 (44%)
Progress to heart transplant or LVAD work-up		45 (19%)
Unsuitable for heart transplant or LVAD due to contraindications		69 (29%)
Awaiting decision or missing data		19 (8%)
Reasons for AHF treatment unsuitability for outpatient referrals		Total N (%)
Reversible/modifiable contraindications	Active smoker	10 (14%)
	Active recreational drug use	0
	Alcohol excess	3 (4%)
	Psychosocial	9 (13%)
	Frailty	9 (13%)
	High BMI	28 (41%)
Irreversible contraindications	Vascular	6 (9%)
	Poor lung function	10 (14%)
	Cognitive impairment	2 (3%)
	Liver or kidney failure	15 (22%)
	Diabetes-related end-organ damage	18 (26%)
	Other	17 (25%)
Characteristics of inpatient referral cohort		Total N (%)
Total number of interhospital inpatient transfers		182 (44%)
No inotropes IABP or stMCS		61 (33.5%)
Short term MCS		31 (17%)
Inotropes		85 (46.7%)
No GDMT		73 (40%)
Outcomes of inpatient referrals		Total N (%)
Too well		31 (17%)
Progress to HTx or LVAD work up		57 (31%)
Unsuitable for HTx or LVAD due to contraindications		71 (39%)
No outcome recorded		23 (13%)
Reasons for AHF treatment unsuitability for inpatient referrals		Total N (%)
Reversible/modifiable contraindications	Active smoker	18 (25%)
	Active recreational drug use	5 (7%)
	Alcohol excess	8 (11%)
	Psychosocial	13 (18%)
	Frailty	5 (7%)
	High BMI	19 (27%)
Irreversible contraindications	Vascular	4 (6%)
	Poor lung function	4 (6%)
	Cognitive impairment	1 (1%)
	Liver or kidney failure	27 (38%)
	Diabetes-related end-organ damage	18 (25%)
	Other	18 (25%)

AHF, advanced heart failure; BMI, body mass index; GDMT, guideline directed medical therapy; HTx, heart transplantation; IABP, intra-aortic balloon pump; ICD, implantable cardioverter defibrillator; IQR, inter quartile range; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; MCS, mechanical circulatory support; MCS, mechanical circulatory support; N, number; NT-proBNP, N-terminal-pro-brain natriuretic peptide; NYHA, New York Heart Association; RAAS, renin–angiotensin–aldosterone system; SGLT2, sodium-glucose co-transporter-2; stMCS, short term mechanical circulatory support.

Advanced heart failure criteria

Among outpatient referrals, the prevalence of key ‘I NEED HELP’ criteria was as follows: 65% were in NYHA class III–IV symptoms, 53% had either an NT-proBNP >1000 pg/mL or BNP >300 pg/mL, 24% had cardiorenal or cardiohepatic dysfunction, 65% had an LVEF <30%, 19% had a history of appropriate shocks from their ICDs, 36% had more than one unplanned clinic visit or hospitalisation in the past year, 26% had persistent congestion with rising diuretic requirement, 5% had a systolic blood pressure <90 mm Hg, and 18% were unable to tolerate GDMT.

Among inpatients, 47% required intravenous inotropes and 17% were supported with short-term mechanical circulatory support at the time of referral.

Outcomes following initial assessment

Among outpatient referrals, 44% were considered too well for HTx or LVAD therapy at initial review, meaning the transplant cardiologist judged that their prognosis with ongoing medical therapy was likely superior to that following advanced intervention. In contrast, 19% of outpatients proceeded to full assessment for advanced therapies (figure 2).

Figure 2. Flow diagram of outcomes of all referrals for advanced heart failure between January 2024 and April 2024, including proportions deemed suitable, unsuitable, or too well for intervention. BMI, body mass index; HTx, heart transplant; LVAD, left ventricular assist device.

Among inpatient referrals, 17% were similarly deemed too well and were discharged with a plan for continued GDMT, while 31% underwent a comprehensive evaluation for HTx or LVAD.

Inadequate or unsuitable referrals

Among outpatient referrals, 29% were found unsuitable for HTx or LVAD due to contraindications. The most common reasons for unsuitability were: (1) 41% had a body mass index (BMI) >35 kg/m²; (2) 26% had poorly controlled diabetes with end-organ damage; (3) 18% were active smokers or drank excessive amounts of alcohol; and 16% were deemed too frail or cognitively impaired (figure 2).

Among inpatient referrals, the common reasons for unsuitability were: (1) 27% had a BMI >35 kg/m²; (2) 25% had poorly controlled diabetes with complications; and (3) 36% had psychosocial contraindications (eg, active substance misuse, poor support).

The reasons for unsuitability were grouped into those that are modifiable (eg, obesity, frailty, active smoking, recreational drug use and psychosocial issues) and those that are irreversible in order to understand the proportion of AHF referrals who could potentially benefit from early access to support services to reverse these contraindications (see table 1). Weight-loss programmes, addiction support, psychological assessment and support interventions could help such patients access advanced therapies.

Equity of access

A heatmap was generated to visualise geographic variation in referral rates for HTx and LVAD assessment (figure 3). Regions were categorised by referral rate per million population—green: >9 referrals/million; yellow: 6–9 referrals/million; amber: 3–6 referrals/million; red: <3 referrals/million. A heatmap of referral rates for HTx and LVAD assessment per million population ages 16–69 (ie, transplant eligible ages) was also made (figure 4).

Figure 3. A heatmap of referral patterns across UK and Ireland based on postcode region. Red <3 per million population, orange 3 to 6 per million population, yellow 6 to 9 per million population, and green >9 per million.

Figure 4. A heatmap of referral patterns across England, Wales and Northern Ireland based on postcode region, per million population, adjusted for ages 16–69 years. Red <5 per million population, orange 5 to 10 per million population, yellow 10 to 15 per million population, and green >15 per million.

Even after accounting for transplant-eligible age in the UK population, pronounced regional disparities were observed. Areas with the lowest referral rates included Wales, Northern Ireland, North England, North Midlands, South and Southeast England. In contrast, parts of North West England, South Midlands, Southeast England and Southwest England demonstrated higher referral rates.

Online supplemental table 1 provides descriptive statistics for the study variables. The mean referral counts per post code area without adjusting for age-eligible population size was 3.216±2.442. The mean number of referrals per million age-eligible population was 6.294±4.738, with a range from 0 to 30.116. The mean of median IMD rank by postcode area was 16 872.268±5002.519. The mean driving time from the centroid of the postcode area to the nearest transplant centre was 1.135±0.585 hours.

Online supplemental table 2 shows the results of the negative binomial regression models. Model 1 regresses referrals on driving time to the nearest transplant centre. Model 2 regresses referrals on postcode area median IMD rank. Finally, model 3 regresses referrals on both driving time and median IMD rank. Distance to nearest transplant centre and deprivation were not significantly related to referrals in any of the models shown in the table (p>0.05). This indicates that adjusting for the total age-eligible population, the number of referrals was not found to be significantly associated with distance from transplant centres or median IMD rank within postcode area.

Summary and interpretation

Principal findings

The 2024 UK and Ireland National Advanced Heart Failure Audit Report is the first comprehensive national evaluation of referral patterns for HTx and LVAD assessment. This study provides important new insights into the contemporary landscape of referrals for patients with AHF. It reveals significant regional variation in referral rates that persists even after adjusting for age eligibility and population size. Contrary to expectations, neither distance to transplant centres nor socioeconomic deprivation were significantly associated with referral rates. A substantial proportion of referred patients were deemed unsuitable for advanced therapies, primarily due to potentially modifiable clinical and psychosocial contraindications such as obesity, poorly controlled diabetes and substance misuse. These findings suggest variability in clinician awareness and referral practices across regions and indicate a need for increased education, co-produced, standardised, referral criteria and broader service access working across national devolved healthcare boundaries. These data likely also reflect a lack of standardisation of HF specialist services across the UK, with good provision in some areas and poor or no provision in others.

Moreover, many patients not suitable for HTx or LVAD may still benefit from improved access to specialist palliative care. Data from the Olmsted County study suggest that 13.7% of patients with HF meet the ESC criteria for AHF, with similar prevalence (approximately 6–7%) in both men and women and a 50% 1-year mortality rate.³

Applied to the UK population, this would equate to an estimated 134 000 people requiring either HTx, LVAD therapy or specialist palliative care. Despite this, only around 300 patients currently receive HTx or LVAD annually. Similarly, in Ireland, using HF prevalence estimates from the Central Statistics Office, we estimate that at least 6800 individuals are living with AHF.^{3 11} However, fewer than 25 AHF surgical therapies (HTx or durable LVAD implantation) are performed annually. This highlights a substantial unmet clinical need in both Ireland and the UK. While improving access to advanced therapies remains essential, these findings also carry significant policy implications. There is a need to ensure that comprehensive palliative care services are available and appropriately resourced for the majority of patients with AHF who are unlikely to become candidates for HTx or LVAD.

Our data also revealed a gender difference in referral patterns. Although women comprise approximately 50% of the AHF population, women represented only one in three of those referred for specialist assessment.^{1 3} This aligns with international data showing that women make up only about one in four of all heart transplant recipients.¹² While this suggests potential under-referral, the study was not designed to determine whether this reflects referral bias, differences in symptom profile or biological differences in HF phenotype.

Strengths and weaknesses of the study

A major strength of this study is its national scope, incorporating data from all seven transplant centres over a defined period, providing a robust baseline for referral patterns for future comparisons. The detailed characterisation of patients and evaluation of suitability criteria adds important granularity to our understanding of real-world contemporary practice. While prior research has estimated the prevalence of AHF and the possible demand for HTx/LVAD therapies, this study uniquely evaluates actual referral behaviours within a national healthcare system and provides new insight into the proportion of referred patients who are truly eligible for these advanced therapies. Unlike studies that suggest geographical or deprivation-related barriers to access, our findings show no clear association with these factors, highlighting that referral variability may be more influenced by local clinical culture or knowledge gaps.

However, limitations of this study include the use of postcode areas which may not perfectly capture socioeconomic status or population heterogeneity. Postcode areas are not official statistical geographies for IMD measurements and postcode areas may contain substantial internal variation in socioeconomic conditions. The use of postcode area unweighted averages in IMD scores may therefore not reflect population-weighted deprivation.

In addition, the lack of data covering the full care pathway (including access to specialist palliative care services) limits the extent to which we can fully understand downstream outcomes for patients who were not considered candidates for HTx or LVAD therapy. The relatively short 4-month data collection window also does not allow comprehensive assessment of seasonal or temporal fluctuations in referral behaviour and therefore may affect the generalisability of our findings over longer time periods. Although referral activity at participating centres has historically shown minimal seasonal variation, extended longitudinal data collection will be required in future audit cycles to confirm the representativeness of this initial period.

Although this audit demonstrates pronounced regional variation in referral rates, we acknowledge that the absence of regional data on the prevalence of AHF limits our ability to determine whether this variation represents true inequity or reflects differences in underlying disease burden.

All centres follow shared international guidelines for HTx/LVAD candidacy, using cardiopulmonary exercise testing and right heart catheterisation as part of a broader assessment of prognosis and suitability. The designation of ‘too well’ reflects each centre’s multidisciplinary team judgement that a patient is likely to do better with continued medical therapy than with HTx/LVAD. This audit did not assess how this judgement varied between centres. This should be explored in future audit cycles.

Unanswered questions and future research

Future research should explore the underlying causes of regional variability in referral patterns, including qualitative work on clinician decision-making and referral behaviours. This study found potentially modifiable contraindications to advanced therapies are common, such as obesity. There is a need to assess regional access to services that support the optimisation of AHF patients with potentially modifiable contraindications, including weight management programmes, diabetes optimisation services, psychological support and addiction services. The availability of these services is likely to vary between regions. Additionally, studies should assess the full care pathway, including the role and accessibility of palliative care services for patients with AHF who are ineligible for HTx or LVAD therapy. Longitudinal data collection will be important to monitor the impact of any quality improvement initiatives on referral equity and patient outcomes.

Conclusions

There is substantial variation in referrals for AHF therapies across the Republic of Ireland and the four nations of the UK, which does not appear to be associated with either proximity to the nearest transplant centre or levels of socioeconomic deprivation. These findings suggest that significant potential inequities in access to HTx and LVAD therapies persist. Notably, women are less likely to be referred than men. These findings have important implications for national healthcare planning, including workforce development and allocation of public health resources. Further work is required to investigate barriers to referral, enhance clinician awareness and optimise care pathways for patients in need of both life-prolonging and supportive therapies.

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.