{
  "abstract": "Heart failure (HF) remains a relentless global health challenge, characterised by significant morbidity, mortality and healthcare expenditure. In recent years, the contemporary management of patients with HF with reduced ejection fraction has been shaped by the consolidation of four foundational pharmacological pillars: beta-blockers, renin-angiotensin system inhibitors or angiotensin receptor-neprilysin inhibitors (ARNI), mineralocorticoid receptor antagonists and sodium-glucose cotransporter-2 inhibitors (SGLT2i). Despite robust clinical practice guidelines advocating for the comprehensive use of these agents, real-world implementation continues to lag behind sharp pharmacological development. Contemporary registries highlight this concerning situation; while the use of individual agents is reasonably high, less than half of patients are prescribed quadruple therapy and a mere 1% achieve the target doses for all recommended drug classes.1 Crucially, the reasons for non-prescription or underdosing can rarely be attributed to documented side effects or intolerances, pointing instead towards systemic barriers and physician clinical inertia. This implementation gap underscores the urgent need to define pragmatic strategies for optimising guideline-directed medical therapy. When faced with an ambulatory patient already receiving conventional neurohormonal blockade, clinicians frequently grapple with the sequence of introducing newer agents: should an ARNI or an SGLT2i be prioritised? Concurrently, in the era of novel diuretic-sparing therapies, does the specific choice of loop diuretic still hold clinical relevance?",
  "authors": [
    {
      "affiliations": [
        "Cardiology, IMIBIC, Córdoba, Spain",
        "Cardiology, Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain"
      ],
      "name": "Rafael Gonzalez-Manzanares"
    },
    {
      "affiliations": [
        "Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain",
        "Son Espases University Hospital, Palma, Spain"
      ],
      "name": "Xavier Rossello"
    }
  ],
  "title": "Methodological lessons of implementation trials in heart failure",
  "uid": "d3ba606f-fb25-5a8b-86cc-b160fa3744a6"
}