Guideline adherence for the management of cardiovascular disease in primary care: a scoping review

Abstract

Background

Worldwide, cardiovascular diseases (CVDs) persist as a leading cause of mortality. Clinical practice guidelines (CPGs) aim to support evidence-based decision-making and improve outcomes in primary care. However, application of these guidelines is often inconsistent, raising concerns about potential unconsidered barriers to implementation.

Objectives

This review aimed to assess the extent to which CVD-related CPGs are followed in general practice and factors influencing the application.

Methods

A structured literature review was conducted in August 2025 in accordance with the PRISMA-ScR guidelines, using MEDLINE (PubMed), Cochrane Library, and Web of Science. The inclusion criteria comprised original studies in English or German that focused on CPG adherence in primary care related to CVDs.

Results

After screening 791 studies, 37 were included. Most of these studies had a cross-sectional design and were conducted in Europe. Reported CPG application varied considerably, ranging from 4% to 100% depending on the disease area and evaluation method. Factors influencing CPG application included time constraints, systemic factors, and limitations within the guidelines themselves. Especially complex cases led to concerns about side effects and to deviations from the guideline.

Conclusion

Despite high awareness, the adherence to cardiovascular guidelines in general practice has a high variance. As patients in primary care are often multimorbid, evidence-based recommendations often need to be tailored to the patient's needs. Guideline enhancement should therefore emphasize practicality, comprehensibility, and the incorporation of general practitioners’ viewpoints.

Key Messages.

• Guideline adherence in general practice is often heterogenous, as GPs need to deviate the needs in complex cases.

• Time constraints, disagreement, patient engagement and adherence, and side effects/interactions were the most common reasons for non-application.

• Guideline enhancement should emphasize practicality, comprehensibility, and the incorporation of GPs’ viewpoints.

Introduction

Cardiovascular diseases (CVDs) remain the leading cause of morbidity and mortality worldwide, accounting for approximately one-third of all annual deaths [1]. Given the high prevalence and preventability of CVDs, clinical practice guidelines (CPGs) have been established to optimize clinical practice in the diagnosis, treatment, and management of CVD. CPGs are systematically developed recommendations that support clinical decision-making and reflect the current state of scientific knowledge and evidence-based practice [2]. There are several national and international guidelines, some of which differ significantly between countries. Furthermore, inconsistencies have been identified within the extant guidelines regarding a single disease pattern. For instance, a comparison of worldwide hypertension guidelines demonstrates considerable discrepancies in the threshold values and treatment strategies [3]. In addition to differences between countries, there are also different recommendations within one country that could be considered. With regard to the example of hypertension in Germany, three major guidelines exist that demonstrate considerable overlap in many areas, whilst also suggesting divergent approaches for specific topics [4]. For example, the target blood pressure to be achieved through therapy is a strict target value independent of age, which differs between guidelines. However, recommendations also exist for target values lying within a risk- and age-dependent range [5–7]. Examining general practices in Germany reveals the existence of a fourth guideline that could be taken into account [8]. Translating these various recommendations into clinical practice remains challenging.

This is particularly apparent in the context of primary care. General practitioners (GPs) are often the first point of contact for patients suffering from CVD and play an important role in the long-term management and secondary prevention of disease. In general practices, clinicians have to balance standardized care for many different conditions in often multimorbid patients with the individual needs of those patients [9]. Therefore, the importance of evidence-based guidelines is high. While GPs are expected to follow the recommendations of these guidelines, they also need to consider a number of other factors including the prevalence of co-morbidities, patient preferences, and systemic barriers such as limited time and resources [10]. Although guidelines for CVDs are widely available and easy to access, research has consistently shown that adherence to guidelines in primary care is variable, suggesting that structural and behavioural barriers may exist [11]. Furthermore, in complex clinical situations, deviating deliberately from guidelines may not necessarily indicate poor quality, but rather an informed, personalized decision [12]. More specifically, adhering to guidelines designed primarily for the treatment of single diseases could have undesirable consequences when treating elderly individuals with multiple comorbidities [13].

Therefore, the aim of this review is to provide an overview of the current level of guideline application for the management of CVD in general practices. Primary objective is to demonstrate the current level of guideline adherence. Structural and individual barriers should be identified to help develop practical recommendations for GPs.

Methods

Study design

This scoping review was conducted based on the PRISMA-ScR Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews (Supplementary File S1). A study protocol for this review has not been registered or published. As this study is a review of previously published literature, ethical approval was not required.

Data sources and search strategies

A structured literature research was conducted in October 2023 using three electronic databases: MEDLINE (via PubMed), Cochrane Library, and Web of Science. The initial search strategy was developed by the first and second authors and subsequently refined by the entire team. The search strategy employed terms from the Medical Subject Headings (MeSH) along with additional keywords specific to the topic and the respective database. Boolean operators (AND, OR) were used to refine the search. The main keywords used in the literature search were ‘guideline adherence,’ ‘primary care,’ ‘family practice,’ ‘general practitioner,’ and ‘cardiovascular diseases.’ The full search strategy using PubMed as an example is shown in Fig. 1. The initial search was last updated in August 2025 to ensure comprehensive incorporation of the most recent literature. To identify additional relevant articles, a hand search was conducted by reviewing the reference lists of the included studies. The publications found in the search were entered into Covidence [14].

Figure 1.

Search strategy PubMed.

Inclusion and exclusion criteria

The authors collectively determined the inclusion and exclusion criteria. Studies were included if they were available in English or German, took place in a primary care setting, and made a relevant statement to the research question. Studies were excluded if they did not take place in a primary care setting, if they did not involve GPs/family doctors/general internists, and if the full text was not available. Additionally, randomized controlled trials (RCTs) were excluded as the focus of this study was on the actual level of guideline adherence, rather than the effects of an intervention or implementation strategies. Besides RCTs, other reviews were excluded. But any reviews meeting the inclusion criteria were checked for original research articles, which were then included individually in the selection process. There was no restriction on the date of publication.

Study selection and data extraction

Following the removal of duplicates, two independent reviewers (EZ and PT) screened the research results by title and abstract for relevance, followed by a full-text screening based on the inclusion and exclusion criteria previously mentioned. In case of disagreement on the relevance of the studies, a third, independent reviewer (CS) was involved, and the conflict was resolved by discussion.

A standardized data extraction form was developed by EZ and PT and adapted to collect key information from the included studies, including general information (e.g. country, year), study characteristics (e.g. study's aim, design, participants), main findings in relation to the research question (e.g. application, reasons for adherence or non-adherence), and key conclusions. The extraction of data was conducted by two reviewers (EZ and PT), independently. Any discrepancies that arose were resolved through discussion. If the resolution of a discrepancy was not possible through discussion, a third reviewer (CS) was involved. The extracted data was synthesized narratively, and key themes were identified.

Results

Study selection

After removing duplicates, 791 studies remained for title and abstract screening. By applying the above inclusion and exclusion criteria, 78 studies remained for full-text screening. Of these, a total of 37 were included in the review [15–51]. The flowchart is provided in Fig. 2.

Figure 2.

PRISMA flowchart.

Study characteristics

Of the included studies, 26 had a cross-sectional design. The study population consisted of either physicians (mostly GPs) or a specific patient group to examine the adherence of the respective physicians. The most recent study was published in 2025 [32] and the oldest one in 1998 [28]. Twenty-two of the studies were conducted in Europe. Table 1 provides a detailed overview of the included studies.

Table 1.

Characteristics and outcomes of included studies.

Author, year, country [Reference]	Title	Study design and population	Outcomes and key conclusion (KC)
Hypertension
Bannow et al., 2021, Germany [15]	Umsetzung der Empfehlungen der ESC/ESH-Hypertonie-Leitlinie 2018 in der hausärztlichen Praxis	Cross-sectional study, 259 family physicians	Agreement with key revised guideline recommendations varied between 40% and 94% for the individual recommendations, while implementation (practical adherence in case examples) varied between 4% and 72%. KC: The guideline is well accepted but not consistently implemented, especially regarding combination therapy and targets in the elderly
Heneghan et al., 2007, United Kingdom [16]	Hypertension guideline recommendations in general practice: awareness, agreement, adoption, and adherence	Cross-sectional study, 401 GPs	Awareness of statin therapy was 99%, and adherence was 43%. For BP measurement in both arms, awareness was 77%, and adherence was 13%. For verbal advice on lifestyle changes, awareness was 97%, adoption was 85%, and adherence was 13%. Adoption = implementing it “more than half of the time”, Adherence = applied it “always” or “more than half the time” KC: GPs often do not adopt recommendations despite high awareness, and most GPs are unlikely to implement elements of guidance they disagree with
Hyman et al., 2000, United States [17]	Self-reported hypertension treatment practices among primary care physicians: blood pressure thresholds, drug choices, and the role of guidelines and evidence-based medicine	Cross-sectional study, 316 physicians	41% of respondents who treated hypertension had either not heard of the JNC-V guidelines or had heard of the report but were not familiar with the contents. Familiarity with JNC-V guidelines was linked to more aggressive BP targets. KC: Many physicians have higher BP thresholds for the diagnosis and treatment of hypertension than the 140/90 mm Hg criterion recommended by the JNC-V guidelines
Kempegowda et al., 2019, United Kingdom [18]	Managing hypertension in people of African origin with diabetes: Evaluation of adherence to NICE Guidelines	Cross-sectional study, 78 patients	36% of participants were on the NICE-recommended antihypertensive combination In the group of patients with suboptimal BP control, adherence to the NICE guidelines was 48.6%. In the optimal BP control group, adherence was 25.6%. KC: Adherence to NICE guidelines in African origin patients with T2DM and hypertension appeared to be poor in this setting
Midlöv et al., 2008, Sweden [19]	Barriers to adherence to hypertension guidelines among GPs in southern Sweden: a survey	Cross-sectional study, 90 GPs	94% acknowledged BP target levels, but many GPs initiated treatment at higher-than-recommended BP thresholds. 20% of patients reached the target BP levels, and 53% used risk assessment programs. KC: GPs in southern Sweden often accept higher BP levels than recommended. Patient age, particularly old age, was a major barrier to initiating pharmacological treatment for hypertension
Steinman et al., 2004, United States [20]	Clinician awareness of adherence to hypertension guidelines	Cross-sectional study, 86 PCPs	Clinicians estimated that 75% of their patients were prescribed medications concordant with guidelines, actual adherence (of JNC-VI guidelines) was 60%. 68% expected patients to achieve the target BP of <140/90. 43% of patients achieved this target. KC: Clinicians slightly overestimated their adherence to medication guidelines and substantially overestimated their adherence to blood pressure target
Vatani Nezafat et al., 2020, Iran [21]	Adherence of General Practitioners to the National Hypertension Guideline, Isfahan, Iran	Cross-sectional study, 43 GPs and 377 patients	The mean score of compliance of physicians with the guideline observed was 33.6 ± 16.42%. Adherence in the treatment part (31.8 ± 18.16%) was lower than the diagnosis part (34.2 ± 21.22%). KC: The study found that adherence to the national hypertension guideline among family physicians was low although they thought that they have acceptable adherence
Cholesterol management
Akhabue et al., 2017, United States [22]	Implications of American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Guidelines on Statin Underutilization for Prevention of Cardiovascular Disease in Diabetes Mellitus Among Several US Networks of Community Health Centers	Cross-sectional study, 32 440 patients	28.2% were concordant with ACC/AHA only, 11.6% with ATP III only. 24.5% were concordant with both guidelines. Overall, 36.2% were concordant with ATP III and 52.8% with ACC/AHA. 35.5% met neither ATP III nor ACC/AHA. KC: The study highlighted significant opportunities to improve cholesterol management in diabetic patients within community health centers to enhance CVD prevention
Almigbal et al., 2023, Saudi Arabia [23]	Physicians’ perceptions and beliefs on the current dyslipidemia management practices within Saudi Arabia	Cross-sectional study, 467 PCPs and specialists	In line with the 2018 AHA/ACC/multisociety guidelines for lipid management, 77.9% of the physicians prescribed statins to diabetic patients aged 40–75 years. KC: The study concluded that there are different perceptions and attitudes among physicians in Saudi Arabia regarding lipid guidelines, with multiple challenges and action gaps between specialists and PCPs. Most Saudi Arabian physicians use non-standardized clinical practices regarding guideline selection, risk stratification tools, lipid panels, non-HDL-C targets, non-statin therapies, and different forms of dyslipidaemia. Standardized practices are recommended to improve dyslipidaemia management and health outcomes
Backlund et al., 2004, Sweden [24]	The role of guidelines and the patient's life-style in GPs’ management of hypercholesterolaemia	Qualitative research, 20 GPs	Adherence was 85% for CHD and 50% for diabetes. In the primary prevention cases, adherence was 35% for high risk, 40% for moderate risk, 100% for low risk, and 30% for family history. KC: The data from the present study indicate that most doctors make the distinction between primary and secondary prevention in their decisions, but that recent modifications of the guidelines, e.g. the importance of previous stroke, are less well implemented. While doctors were aware of key guideline elements, lifestyle factors frequently influenced treatment decisions.
Backlund et al., 2004, Sweden [25]	GPs’ decisions on drug treatment for patients with high cholesterol values: a think-aloud study	Think-aloud study, 20 GPs	Guideline-adherent treatment in the different cases varied between 35% and 100%. KC: GPs’ decisions on cholesterol treatment were influenced by different perspectives and interpretations of risk, leading to inconsistent application of guidelines
Bally et al., 2010, Switzerland [26]	Barriers to Swiss guideline-recommended cholesterol management in general practice	Cross-sectional study, 866 patients	Guidelines were followed in 43.9% and not followed in 56.1% of all cases. Diagnostic Non-Adherence in 46%, treatment non-adherence in 19% of all patients and in 33% of those with an indication for treatment. KC: More than half of all patients aged 35–80 were not screened or treated according to current guidelines, due to both patient- and physician-related reasons
Goldberg et al., 2007, United States [27]	Survey of physician's attitudes and practices toward lipid-lowering management strategies	Cross-sectional study, 78 general internists and family practitioners	The respondents followed Adult Treatment Panel III guidelines for the treatment of patients with hyperlipidaemia either all (15%) or most (77%) of the time KC: Despite adequate physician knowledge, achieving desirable serum lipid levels in primary care patients remains elusive
McBride et al., 1998, United States [28]	Primary care practice adherence to National Cholesterol Education Program guidelines for patients with coronary heart disease	Cross-sectional study, 603 patients of 159 PCPs	33% of the patients were not screened with lipid panels. 45% did not receive dietary counselling. 67% were not prescribed cholesterol-lowering drugs. KC: This study of a wide range of community-based primary care practices indicates that PCPs did not consistently follow the recommendations of the second National Cholesterol Education Program ATP-II in the 2 years after the release of the guidelines
Núñez-Cortés et al., 2019, Spain [29]	Management of atherogenic dyslipidemia according to current treatment guidelines: DESPEGA study in real clinical practice	Cross-sectional study, 980 physicians	77.3% of the physicians reported that they used guidelines for the management of patients with atherogenic dyslipidaemia (AD) in their clinical practice. 83% of physicians adhered to guideline recommendations in more than four of the six patient cases (31.1% four, 37.1% five, and 14.7% six profiles). KC: Adherence to guidelines for AD management was high in treatment areas but could be improved in diagnosis and definition of AD
Rachamin et al., 2020, Switzerland [30]	Guideline Concordance of Statin Treatment Decisions: A Retrospective Cohort Study	Cohort study, 8060 patients	63.0% of treatment decisions were guideline concordant, 35.8% undertreatment, 1.2% overtreatment. 84.4% of patients for whom statin treatment was recommended were not initiated on a statin (undertreatment). For patients at high risk in 69.8%, and for patients at very high risk in 75.7%. KC: Overall, the statin treatment decisions were guideline-concordant in two-thirds of patients. Even though patients at high or very high CV risk were often undertreated, we found that GPs considered CV risk and LDL-C in their treatment decisions. Guideline deviations might partly be explained by GPs following a personalized approach for each patient
Vashitz et al., 2011, Israel [31]	Adherence by Primary Care Physicians to Guidelines for the Clinical Management of Dyslipidemia	Post hoc analysis of data from a prospective cluster randomized trial, 7745 patients across 130 PCPs	For lipid profiles, literal adherence was 35%, and substitute adherence was 30%. For pharmacotherapy initiation, literal adherence was 26%, and substitute adherence was 24%. Regarding up-titration of pharmacotherapy, literal adherence was 16%, and substitute adherence was 76%. Regarding referral for metabolic consultation, literal adherence was 4%, and substitute adherence was 79%. There was literal adherence in 25% and substitute adherence in almost 50%. substitute adherence = practicing different measures than those recommended in the guidelines (mostly less intense actions) KC: In real-life clinical practice, literal adherence with dyslipidaemia prevention guidelines was poor. PCPs tended to follow the guidelines literally in simple clinical cases but chose substitute measures in complex cases
Primary/secondary prevention
Almehwari et al., 2025, Saudi Arabia [32]	Bridging the Gap in Cardiovascular Disease Prevention: Evaluating Family Physicians’ Knowledge and Application of Guidelines in Primary Care	Cross-sectional study, 200 Family physicians	The most frequently used guidelines were the European ones (67.3%), followed by national guidelines (25.7%). 14.2% had an acceptable guideline knowledge score (≥70%). 48.7% achieved an acceptable score (≥70%) in guideline application. The mean application score was 69.7%, and the average knowledge score was 56.5%. KC: There are significant knowledge and application gaps among family physicians regarding CVD prevention guidelines
Brotons et al., 2013, Spain [33]	Implementation of Spanish adaptation of the European guidelines on cardiovascular disease prevention in primary care	Cross-sectional study, 1390 PCPs	Of the physicians who were aware of the guidelines, 62% used them in clinical practice (36% of all physicians), and 38% stated they were employing a different set of local or international guidelines. Family doctors being more likely than general doctors to be aware of and use the recommendations (60.1% versus 53.4%). KC: While awareness of CEIPC guidelines is high, implementation in clinical practice is limited. Risk assessment tools are underused.
Fhärm et al., 2009, Sweden [34]	Aiming for the stars'-GPs’ dilemmas in the prevention of cardiovascular disease in type 2 diabetes patients: focus group interviews	Qualitative research, 14 GPs	Five dilemmas in the prevention of CVD in type 2 diabetics: Label someone who feels healthy as ill; frighten or comfort the patient; take responsibility for the care or not; conflict between lifestyle changes and drug treatment; integrate science into reality. KC: This study has identified problem areas in the GPs’ approach to diabetes patients that might have substantial impact on the outcome of diabetes care, communication, and the prevention of cardiovascular complications. The study revealed scepticism about treatment targets in guidelines. GPs have also expressed the need to tailor treatment to the individual patient
Freier et al., 2020, Germany [35]	Prescribing and medical non-adherence after myocardial infarction: qualitative interviews with general practitioners in Germany	Qualitative research, 16 GPs	Almost all GPs reported that they follow guidelines independently of patients’ type of MI and gender, and that they continue to prescribe the medication that was initiated in the hospital. Almost half of the interviewed GPs had not prescribed one or two of the recommended drugs in patients who had had an MI. KC: The study concluded that while GPs generally follow guidelines, they face challenges related to patient-specific factors such as side effects and non-adherence. GPs often seem to rely on hospitals’ discharge medication. GPs should check these for accordance with the guidelines. Almost all GPs reported that they follow guidelines. GPs partly question the effects of secondary prevention for the oldest of patients
Heidrich et al., 2005, Germany [36]	Knowledge and perception of guidelines and secondary prevention of coronary heart disease among general practitioners and internists. Results from a physician survey in Germany	Cross-sectional study, 681 GPs and office-based internists	Adherence to lipid-lowering drug treatment was 31.5% with respect to total cholesterol and 33.7% for LDL-cholesterol. Guideline knowledge was independently associated with treatment of elevated total cholesterol levels and elevated LDL-C levels. Adherence to drug treatment of elevated blood pressure was 62.8% for systolic BP and 73.9% for diastolic BP. Guideline knowledge was not associated with both KC: The study concluded that while guideline knowledge led to better treatment practices for cardiovascular risk factors, there was substantial room for improvement in adherence
Kamyar et al., 2007, Scotland [37]	Adherence to clinical guidelines in the prevention of coronary heart disease in type II diabetes mellitus	Cross-sectional study, 208 patients	Overall adherence to the guideline criteria was 77.2%. Non-adherence was justified in 3.7% and unjustified in 19.0%. Adherence to the CPG criteria for secondary prevention was 74.4%, and for primary prevention, it was 80.1%. KC: The study concluded that adherence to guidelines for coronary heart disease prevention in diabetes care is high but leaves room for improvement, particularly in secondary prevention measures
Lopez-Carmona et al., 2011, Spain [38]	Compliance with cardiovascular drug prevention measures in a general population: the Multidisciplinary Intervention in Primary Care (IMAP) study	Cross-sectional study, 2270 patients	Subjects with two or more classical cardiovascular risk factors (diabetes, hypertension, dyslipidaemia, smoking), as compared with those with zero or one risk factor, had a greater tendency to undertreatment for all cardiovascular drugs, and to overtreatment with antithrombotic and ACE-inhibitors/angiotensin receptor blockers (ACEI/ARB). Statins: 23% with indication, 7.8% treated subjects, 19.5% untreated with indication ACEI/ARB: 12.5% with indication, 11% treated subjects, 8.6% untreated with indication KC: The study shows the existence of an important gap between current guidelines on cardiovascular drug prevention and clinical practice in the field of primary health care in Malaga, Spain. While a significant percentage of the population received unnecessary drug treatment, another important segment of the population at risk (particularly patients with non-coronary CVD and the elderly) was not being treated
McKinlay et al., 2007, United States [39]	Sources of variation in physician adherence with clinical guidelines: Results from a factorial experiment	Factorial experiment, 128 PCPs	High adherence (>50%): acquisition of information regarding provoking factors and patient medical history; examination of the heart, lungs, and abdomen; ordering EKG, haemoglobin, and stress tests; and making dietary recommendations. Lower adherence (<20%): acquisition of information regarding the quality and duration of pain, factors that relieve it, and family history; the examination of the extremities and neck; ordering glucose tests and X-rays; and making recommendations to increase exercise level. KC: Physician adherence to clinical guidelines varied by patient characteristics, such as gender and age, and by physician experience, suggesting a need for targeted interventions to reduce healthcare variations
Pepió Vilaubí et al., 2018, Spain [40]	Adherence to European Clinical Practice Guidelines for Secondary Prevention of Cardiovascular Disease: A Cohort Study	Cohort study, 438 patients	38.6% of the patients received the drug therapies recommended in the European clinical guidelines, and 61.4% did not. No association between adherence to CPG's and patient characteristics (age, sex, education level, marital status). KC: Clinician adherence to European CPGs for secondary prevention of CVD was low in the primary care setting. Having stroke, being diagnosed with hypertension, dyslipidaemia, or diabetes increased the likelihood of receiving the recommended drugs. Adherence to clinical guidelines improved control of LDL-cholesterol but did not significantly improve patient prognosis in secondary prevention
Sheppard et al., 2014, United Kingdom [41]	Missed opportunities in prevention of cardiovascular disease in primary care: a cross-sectional study	Cross-sectional study, 34 975 patients	64% appropriate treatment in accordance with NICE guidelines in primary prevention group, adherence was higher in younger patients and females. In secondary prevention group, adherence to guidelines was 47% with no observed age or sex differences. KC: There were considerable missed opportunities for guideline-concordant treatment in CVD prevention, suggesting a need for improved adherence to national guidelines to optimize the benefits of preventive care
Voogdt-Pruis et al., 2011, Netherlands [42]	Adherence to a guideline on cardiovascular prevention: A comparison between general practitioners and practice nurses	Prospective Randomised trial, 484 patients	57% of patients visiting the GPs received lifestyle and medical intervention. 13% received at least one lifestyle intervention (weight loss, physical exercise, diet, smoking behaviour). KC: Practice nurses adhered better to cardiovascular prevention guidelines, particularly in lifestyle advice, but both groups needed improvement in regular adherence checks
Mixed Topics
Al Sada et al., 2023, Bahrain [43]	Assessing Adherence to Clinical Practice Guidelines Among Primary Care Physicians in Bahrain: A Cross-sectional Study	Cross-sectional study, 143 PCPs	98.0% of the participants reported they were implementing the CPGs in their daily practice. Most implemented were the guidelines on diabetes mellitus (91.3%), hypertension (81.2%), and hyperlipidaemia (69.8%). Male physicians were more adherent to guidelines on hypertension. KC: Most primary care physicians in Bahrain adhere to clinical practice guidelines in their daily practice, and identifying and resolving barriers to adherence could enhance the consistency and quality of care.
Doroodchi et al., 2008, United States [44]	Knowledge and attitudes of primary care physicians in the management of patients at risk for cardiovascular events	Case vignette survey, 562 family physicians and 326 general internists (total 888)	Adherence in a low-risk patient case was 28% for GPs and 37% for general internists for no antiplatelet therapy and 51% for no lipid-lowering pharmacotherapy. Adherence in a high-risk patient case was 72% for GPs and 76% for general internists. KC: The main findings from this study were that guideline concordance in managing low and high-risk CVD patients by primary care physicians significantly varied in treatment and dietary approach, and managing patients according to guidelines was associated with years in practice and volume of patients
Fürthauer et al., 2013, Austria [45]	Patient and physician related factors of adherence to evidence based guidelines in diabetes mellitus type 2, cardiovascular disease and prevention: a cross sectional study	Cross-sectional study, 58 GPs and 501 patients	Non-adherence was 16.3% for hypertension, 4.6% for diabetes mellitus type 2, 30.3% for heart failure, 14.2% for atrial fibrillation, and 27.3% for the use of beta-blockers after myocardial infarction. Non-adherence to secondary prevention of CVD was 20%. In 61.5% of cases, doctors wrongly considered treatment unnecessary. KC: Overall, about 15% of all QI-cases examined in this study were not treated according to the guidelines. Physicians’ lack of knowledge and patients’ lack of awareness account for about 70% of non-adherence, indicating the necessity to improve physician education, and patient involvement
Hageman et al., 2018, Netherlands [46]	Limited Adherence to Peripheral Arterial Disease Guidelines and Suboptimal Ankle Brachial Index Reliability in Dutch Primary Care	Cross-sectional study, 475 patients who were referred by GPs to the vascular surgery outpatient clinic	Rates for the prescription of antiplatelet drugs/anticoagulants (59%), statins (55%), and initiation of supervised exercise therapy (SET) were lower than recommended. KC: Adherence by Dutch GPs to their own society's Peripheral arterial disease guideline has room for improvement. The reliability of ABI measurements is suboptimal, whereas rates of prescription of secondary prevention and initiation of SET as primary treatment for intermitted claudication need upgrading
Karbach et al., 2011, Germany [47]	Physicians’ knowledge of and compliance with guidelines: an exploratory study in cardiovascular diseases	Cross-sectional study, 1152 Physicians	40% of physicians had adequate guideline knowledge. Adherence (correct answers) varied between 74% for CHD, 24% for heart failure, and 11% for hypertension. KC: Knowing guidelines does not necessarily improve implementation in practice. Structural and contextual influences outweigh purely cognitive knowledge in determining adherence
Miyazawa et al., 2019, United Kingdom/Japan [48]	Guideline-Adherent Treatment for Stroke and Death in Atrial Fibrillation Patients from UK and Japanese AF Registries	Cohort study, 4239 patients in Japan, 2259 patients in UK (total 6498)	Approximately half of patients were treated with guideline-adherent antithrombotic therapy (ATT) (58.6% in the Fushimi registry and 50.8% in the Darlington registry), undertreatment of 40.0% and 36.1%, and overtreatment of 1.4% and 13.1%. KC: Half of AF patients received the recommended ATT. Guideline-adherent ATT was linked to a lower risk of stroke and death. No significant interaction was found between the two populations or the influence of ATT on clinical outcomes.
Naicker et al., 2014, Canada [49]	Quality of cardiovascular disease care in Ontario's primary care practices: a cross sectional study examining differences in guideline adherence by patient sex	Cross-sectional study, 4931 patients	Adherence rates were 89% for coronary artery disease medications. For peripheral vascular disease, the adherence rate was 58% for ACE inhibitors and/or angiotensin receptor blockers, 75% for lipid-lowering drugs, and 76.5% for acetylsalicylic acid. Adherence to acetylsalicylic acid for stroke was 80%. Adherence to lipid-lowering drugs for hyperlipidaemia was 91% and for hypertension 94%. KC: These findings highlight some important gaps in the quality of CVD care in primary care practice. Found areas of care in which no sex differences were observed, areas in which men fared worse than women (preventive measures), and areas in which women fared worse than men (prescribing of recommended medications)
Ornstein et al., 1999, United States [50]	Quality of care for chronic illness in primary care: Opportunity for improvement in process and outcome measures	Cross-sectional study, 336 401 patients	Adherence to blood pressure monitoring was 78.5%, and to diagnosis of hypertension (>3× > 140/90 mmHg) was 45%. Adherence to lipid monitoring was 10%, to diagnosis of elevated levels 61%, and to treatment of elevated levels 41.5%. Adherence to the use of antiplatelet agents, unless contraindicated, was 1.4%. Adherence to ß-blockers in patients with a history of myocardial infarction was 13%. Adherence to ACE-inhibitor therapy in patients with heart failure was 21%. The adherence rate for oral anticoagulants in high-risk patients with atrial fibrillation was 29%. KC: The study highlighted considerable variability in guideline adherence across chronic illness measures, suggesting a need for improved guideline incorporation and quality improvement initiatives
Remme et al., 2008, France/Germany/Italy/Netherlands/Poland/Romania/Spain/Sweden/United Kingdom [51]	Awareness and perception of heart failure among European cardiologists, internists, geriatricians, and primary care physicians	Cross-sectional study, 6887 Physicians (2041 cardiologists, 1881 internists/geriatricians, 2965 PCPs)	PCPs showed significantly lower use of ACE-inhibitors, β-blockers, and echocardiography; 43% PCP would always (51% often) prescribe an ACE-inhibitor KC: Despite evidence-based guidelines, between-physician differences in the management of HF persist. In particular, the perceptions of the European PCP and I/G in aspects of HF, including the use of diagnostic techniques and pivotal therapies such as ACE inhibitors and b-blockade, are not optimal

BP, blood pressure; CPG, clinical practice guideline, CVD, cardiovascular disease, GPs, general practitioners; PCPs, primary care physicians.

Amount of guideline adherence

Analysis of the 37 included studies showed that physicians’ awareness and knowledge of CPGs and their use in practice were reported to be high in most studies. However, actual adherence was inconsistent, ranging from 4% to about 100% in some sections (e.g. individual case examples) of the studies. The way in which adherence was measured varied between the individual studies (e.g. questionnaires or analysis of prescriptions expected according to guidelines).

Adherence rates varied between disease areas. Thresholds for starting treatment were often higher than recommended, and use of lifestyle interventions was inconsistent [15–17, 19, 36, 42]. Statins and other lipid-lowering drugs were often not prescribed to high-risk patients [24, 30, 38]. Undertreatment with medication was also observed, particularly in primary prevention, with some studies reporting rates of up to 40% [26, 30, 48]. In contrast, the findings of certain studies demonstrated higher levels of adherence for the purpose of secondary prevention, whilst other studies revealed lower rates [24, 30, 37, 40, 41]. The main outcomes of all included studies are shown in Table 1.

Factors influencing guideline adherence

Physicians’ knowledge of the guidelines and their positive attitudes towards them were associated with higher levels of adherence, although this effect was not universal in all settings or for all guideline areas [27, 29, 36]. Some studies have also considered the physicians’ reasons for deviating from the guidelines and their motivations for following the recommendations. The most common reasons for non-adherence were disagreement with the recommendations [16, 26, 28, 29, 33], patient engagement and compliance [19, 23, 26, 27, 35, 36, 43, 44], concerns about side effects or interactions with other drugs [15, 26, 35, 37, 51], and time constraints [16, 27, 33, 36, 44, 46]. An overview of the studies analyzing reasons for (non-)adherence and their results is given in Table 2.

Table 2.

Reasons for guideline adherence and non-adherence.

Author, year [Reference]	Reasons for adherence	Reasons for non-adherence
Akhabue et al., 2017 [22]	Diagnoses of hypertension and coronary artery disease Any type of health insurance (including Medicaid alone) Being Asian/Pacific Islander or primarily Spanish speaking	Women: less concordant with both guidelines People of colour: lower concordance with ATP III, lower concordance with both guidelines Uninsured patients
Al Sada et al., 2023 [43]	Evidence-based guidelines (79.2%) Address most clinical scenarios seen in daily practice (43.6%) Obligated by institution/department head (31.5%) Easy layout and user-friendly (28.9%) Recommended by a colleague (10.1%)	Need for more knowledge of the guidelines before deciding to apply them (77.6%) Financial budget (53.8%) Clinical practice guidelines are lengthy and not summarized for easy use (47.6%) Patients do not cooperate in applying clinical practice guidelines (41.3%) Other barriers: change their old routines, did not fit into their ways of working
Almehwari et al., 2025 [32]	Higher knowledge scores: middle-aged and senior physicians Higher application scores: female physicians, adherence to national guidelines	Lack of knowledge of preventive measures (62.8%) Lack of counselling skills (37.9%) Complexity and subjectivity of assessment criteria (32.6%)
Almigbal et al., 2023 [23]	Physician familiarity and agreement with the guidelines	Patient-related factors: patient non-adherence, patients’ beliefs and attitudes, and medication cost Physician-related factors: Lack of familiarity with the guidelines, lack of knowledge, and skills to improve patient adherence Practice-related factors: unavailability of timely follow-up appointments, lack of patient education tools, and lack of related lab test
Backlund et al., 2004 [25]	Clear presence of high-risk conditions (e.g. diabetes or CHD)	Personal perspectives (e.g. prioritizing lifestyle change over medication) Inconsistent interpretation of risk Moral judgments (e.g. overweight or smoking seen as patient responsibility) Young age
Backlund et al., 2004 [24]	Patient's inability to change his lifestyle Multiple risk factors	Giving priority to a lifestyle change rather than to drug treatment Arguments against treatment (lack of other diseases and risk factors, a mild form of diabetes, marginally elevated cholesterol)
Bally et al., 2010 [26]	Positive predictors for diagnostic adherence: Higher age Number of consultations Presence of diabetes Elevated triglycerides Positive predictors for overall guideline adherence: Number of consultations in the preceding year Hypertension Cardiovascular event in family Elevated triglycerides Number of risk factors CHD, PAD, and history of stroke	Diagnostic non-adherence: Main reasons: other relevant diseases (45%), the belief that the risk does not require screening (42%) Patient-related reasons: other relevant diseases (45%), the priority of other disease (20%), additional severe comorbidity (20%), patient's unwillingness to take drugs (22%) Physician-related reasons: belief that the risk does not require screening (42%), disagreement with guidelines (33%) Treatment non-adherence: Main reasons: belief that the risk does not require therapy (38%), other relevant diseases (42%), priority of other disease (34%), additional severe comorbidity (32%), patient's refusal to take drugs (33%) Patient-related reason: another relevant disease (42%) Physician-related reasons: belief that the risk does not require therapy (38%), disagreement with guidelines (28%)
Bannow et al., 2021 [15]	n/a	Concerns about side effects (e.g. hypotension, falls) Lack of flexibility in fixed-dose combinations Economic concerns (e.g. fear of reimbursement penalties) Doubts about applicability in older patients
Brotons et al., 2013 [33]	n/a	Time constraints (81%) Too many guidelines (71%) Unrealistic targets (50%) Influence of pharmaceutical industry (36%) Lack of training in lifestyle interventions (48%) Belief that lifestyle advice is ineffective (41%)
Doroodchi et al., 2008 [44]	Less than 10 years’ experience GPs who saw fewer patients with hypertension and dyslipidaemia (25% or less)	Cost of medications (88.8%). Number of medications needed for adequate blood pressure control (74.4%) Patient adherence (73.8%) Presence of co-morbid conditions (58.4%) Adequate time, patient knowledge, skills to recommend dietary changes and facilitate patient adherence (∼50%)
Fhärm et al., 2009 [34]	n/a	Patients’ reluctance to accept chronic illness Conflicts between lifestyle changes and drug treatment
Freier et al., 2020 [35]	GPs cited trust in hospital-initiated prescriptions and adherence to established treatment protocols	Side effects and intolerances Contraindicating comorbidities and interactions with other drugs Concerns about the appropriateness of long-term prevention for elderly patients Patients refusing medication Palliative situations
Goldberg et al., 2007 [27]	High awareness and self-reported knowledge of treatment guidelines Recognition of LDL cholesterol, smoking, and diabetes as key CHD risk factors Belief that guidelines are practical and applicable (85% and 63% agreement, respectively)	Lack of patient compliance (moderately to strongly agree) (72%) Lack of time to adequately use these guidelines during an office visit (22%)
Hageman et al., 2018 [46]	n/a	Limited experience with this disease and unawareness of the availability of SET (supervised exercise therapy) Barriers: time constraints, insufficient staff, equipment availability, training, and skills Low confidence in ABI skills and hesitance to draw conclusions
Heidrich et al., 2005 [36]	Familiarity with guidelines: younger physicians and internists were more likely to be familiar with current guidelines Evidence-based (83.7%) Improve the standard of medical care for CHD patients (82.2%) Useful tool in day-to-day medical practice (80.3%)	Too rigid and to be used in litigation (26.8%) Restrict their medical autonomy (13.3%) Lack of reimbursement Lack of patient compliance Time constraints Physicians’ concerns about the guidelines’ applicability to individual patients Diversity of different guidelines on secondary prevention of CHD
Heneghan et al., 2007 [16]	Financial incentives Agreement with guidelines	Disagreement with recommendations Only few recommendations are universally applicable Impractical in many clinical settings because of limitations in consulting time, lack of local resources, or lack of attention to the logistics of implementation Volume of recommendations and guidelines
Kamyar et al., 2007 [37]	n/a	Possibility for side effects Lack of awareness of and accessibility to guideline
McBride et al., 1998 [28]	Patients with revascularization history or high LDL/TG levels more likely to receive treatment	Physicians were either unaware or did not agree with the guidelines
McKinlay et al., 2007 [39]	Familiarity with certain guideline elements Adherence to common practices	Female patients Older patients: less frequent recommendation to quit smoking Guidelines that relate to primary and secondary prevention, or assessment of important comorbidities may be considered less important at the first evaluation
Midlöv et al., 2008 [19]	n/a	The patient's age is questionable regarding pharmacological treatment (36%) The benefit for the patient is not obvious (32%) Patient's lack of motivation as a reason for abstaining from pharmacological treatment (48%) Pharmacological treatment could lower motivation for lifestyle changes (38%) The patient should first within 6 months try to change lifestyle factors (85%) Low perceived benefit vs. quality of life (30%) Increased blood pressure but all other risk factors within acceptable levels (47%)
Núñez-Cortés et al., 2019 [29]	High satisfaction with guideline outcomes Familiarity with Spanish Society of Primary Care Physicians (SEMERGEN) and ESC/EAS guidelines	Lack of awareness or familiarity with new guidelines Absence of agreement with the guidelines Low self-sufficiency Lack of outcome expectancy
Rachamin et al., 2020 [30]	n/a	Other thresholds than those recommended by the current European guideline might follow national guideline Older GPs might have followed older guidelines using higher LDL-C treatment thresholds Female patient sex
Remme et al., 2008 [51]	n/a	Concerned of side effects
Sheppard et al., 2014 [41]	n/a	Contraindications to therapy Refusal of treatment Failure to examine CVD risk
Vatani Nezafat et al., 2020 [21]	Female physician Attending an empowerment class More experience Graduated from Type I universities	n/a

Discussion

The aim of this review was to provide a comprehensive overview of the extent to which guidelines are being followed in the management of CVDs within general practice and which factors are influencing their application.

This scoping review demonstrates that, despite a high level of awareness and a generally positive attitude towards cardiovascular guidelines, adherence to these guidelines in general practice is often limited.

One reason for the lack of adherence to the guidelines in some of the studies was a lack of knowledge about their contents, as well as a lack of agreement with them. These findings align with the conclusions of other studies, which have identified these factors as significant barriers to guideline adherence [11, 52]. Concerns over the evidence and benefits of the guidelines appear to be an even greater barrier to compliance than a lack of knowledge. For instance, disagreement with recommendations was shown to be a more common barrier than a gap in knowledge [11]. Within this context, it is essential to differentiate the level of evidence supporting these recommendations. For instance, when deliberating the frequently discussed topic of LDL target levels, there are recommendations, particularly in primary prevention, that have only a low level of evidence regarding the recommended low values [53]. Consequently, deviations from such recommendations should be evaluated differently than deviations from recommendations with high evidence.

Inconsistency or selectivity in application was observed, particularly in relation to the use of medication in primary prevention. Studies have found varying levels of adherence in both primary and secondary prevention, with no clear trend apparent. However, some studies have shown higher adherence in secondary prevention settings [24, 30]. Different reasons for this could be discussed. On the one hand, various studies have shown that primary prevention measures are only limitedly effective in some cases. A review on using cardiovascular risk scoring in primary prevention as recommended in different guidelines found that they may have limited effectiveness in reducing CVD events and mortality [54]. A separate analysis indicated that preventive measures, such as statin administration, achieve a comparatively low absolute risk reduction in asymptomatic patients from lower risk groups [55]. On the other hand, people may adhere more to secondary prevention measures because clearer indications or stronger external incentives (e.g. disease management programmes) exist.

Another important factor influencing adherence to CVD guidelines is the limited amount of time available to GPs. Many of the included studies identified lack of time as a major barrier to guideline implementation. This is supported by an analysis, which discusses the ‘Time needed to treat (TNT)’ as an important factor when developing clinical guidelines [56]. This study demonstrates that, despite a high level of medical expertise and a positivity towards guidelines, practical implementation frequently fails due to the impracticality of implementing all recommendations within the timeframe available. To illustrate this point, considering a standard GP practice, the implementation of a screening programme in accordance with the National Institute for Health and Care Excellence (NICE) guideline on physical activity would require an estimated 15% of a GP's total annual patient contact time [56, 57]. This represents a significant challenge, particularly in GP care, which is characterized by high patient numbers and multimorbid cases, in addition to complex dialogue management [56]. It is therefore recommended that realistic time requirements be taken into greater account in the development of future guidelines, and if necessary, that the number and priority of recommendations be adjusted to ensure the practicability of care [56].

In addition to the frequently mentioned problem of time constraints, there are also structural barriers at the level of the guidelines themselves in GP care. Research has indicated that complex formats, overly theoretical language, and a lack of adaptation to healthcare practice play a key role in limited adherence. A potential solution may be the creation of shorter, practice-oriented guideline versions and clearly structured decision algorithms, as well as increased involvement of GPs in the development of these guidelines [58]. A further challenge is the existence of multiple guidelines for the same clinical pictures, for instance from different national specialist societies or international organizations. Different recommendations on the same topic, as well as incomprehensible or missing information, lead to uncertainty among users and present a significant challenge to implementation in everyday practice [59]. In this context, it is also important to consider the quality of the guidelines and the manner in which they are developed. In addition to the methodology, consideration should also be given to potential conflicts of interest on the part of the authors and the underlying studies, as well as how these are addressed. For instance, the website Leitlinienwatch.de provides a platform that evaluates medical recommendations in this regard [60].

Another factor influencing adherence to guidelines can be observed in the context of medical decision-making in complex care situations. GPs frequently report deviations from guidelines, particularly in cases involving patients with multimorbidity or advanced age, where standardized recommendations are not aligned with the overall clinical picture or may conflict with the patient's preferences [15, 19, 35, 39, 44]. This selective application appears to be both unavoidable and medically justified in conditions of real care. A publication addressing the use of CPG in patients with multiple conditions clearly demonstrates that it is not feasible to adhere to each single guideline for such patients. Not only would the patient have to take medications that could interact with each other and cause side effects, but recommendations would partly contradict with each other [13]. Such patients are a common occurrence in general practice, as demonstrated by a recent study from Switzerland, which found that approximately one-third of all patients have three or more chronic conditions, with this proportion rising to more than two-thirds among those over 60 [61]. In those cases, deviations from CPGs may be both appropriate and necessary, which could potentially explain the observed variation in adherence levels from 4% to 100% in this study. Within the German healthcare context, the S3 guideline ‘Multimorbidity’ from the German Society of General Practice and Family Medicine (DEGAM) explicitly emphasizes the necessity of prioritization and contextualization in complex patient cases [62]. Therefore, when creating future guidelines, it should be considered to make clearer distinctions between normative ideal standards and practical feasibility. Moreover, individualized decision-making processes should be recognized as an integral part of medical competence.

Furthermore, the differing socio-economic circumstances of the GPs and the variation in healthcare systems across the study countries may also impact adherence to the guidelines. In the European context, where public funding systems based on the Beveridge and Bismarck models are predominant, the nationwide availability of cardiovascular guidelines is practically guaranteed [63]. However, a study, which was conducted across 12 European countries, revealed that doctors cited limited time as a barrier to the utilization of guidelines [52]. This may also be due to financial reasons. In Germany, for example, remuneration is based on the EBM system (EBM: Einheitlicher Bewertungsmaßstab = Uniform valuation standard). GPs receive a fixed payment per patient, regardless of the length of treatment. As time is not a variable in remuneration, longer consultations or preventive advice are not specifically taken into account in the payment [64]. By contrast, other systems like in the USA are characterized by a high degree of fragmentation and a dominant private sector. Despite reforms such as the Affordable Care Act, around 9.5% of the population under the age of 65 remains uninsured in 2023 [65]. Moreover, of those who are covered by insurance, almost a quarter of working-age adults are underinsured [66]. This directly impacts adherence to guideline-based recommendations, such as preventive measures. It was found that people without insurance and people with temporary insurance were less likely to receive clinical preventive services [67]. When assessing doctors’ adherence to guidelines, these aspects should also be considered.

Strengths and limitations

A key strength of the review lies in the comprehensive search string, which has been adapted to align with various database platforms. Additionally, the entire screening process and the data extraction were both carried out using the dual control principle. An additional neutral reviewer was always consulted in the event of discrepancies.

However, there are some limitations that must also be considered. A methodological limitation of the review is that adherence to guidelines in several studies is based exclusively on self-reports by physicians. This “self-reported adherence’ is subject to potential biases, especially social desirability, which can influence the results (e.g. studies 16,17,19,27,32,33,35,36,43,44,51). In the absence of objective validation, the extent to which adherence corresponds to actual care behaviour remains unclear. However, the findings from these studies have provided valuable insights into attitudes, perceived barriers, and physician understanding of guidelines. This is relevant for the development of practical implementation strategies.

Furthermore, RCTs were excluded from the analysis, as the primary objective was to assess the current state of guideline adherence, rather than the efficacy of specific measures to enhance adherence. The review is therefore based mainly on cross-sectional studies, which are suitable for describing the healthcare situation but have a limited level of evidence and preclude the establishment of causal relationships. This methodological decision results in a reduction of the informative value concerning the causes and mechanisms of action whilst also increasing the practical relevance of the results for current GP care.

Conclusion

This scoping review demonstrates that guideline adherence in general practice for CVDs is heterogenous, despite high levels of awareness and positive attitudes. The barriers to effective implementation of guidelines include the time needed for the specific single treatment, system frameworks, and guideline weaknesses, such as practical unsuitability and prioritization concerns, alongside conflicting recommendations. In addition, in complex care situations, GPs often make a conscious decision to deviate from the guidelines in order to meet individual care requirements. Consequently, non-adherence should not be viewed as inherently negative or inappropriate but rather evaluated within the context of the specific situation.

Supplementary material

Supplementary material is available at Family Practice online.

Funding

This research was supported by resources provided by the Institute of Family Medicine of the University Medical Centre Schleswig-Holstein, Campus Lübeck.

Data availability

This scoping review is based solely on previously published literature; no primary data were collected. The data extraction sheets and tables created during the review process can be obtained from the authors upon reasonable request.