Bridging the gap: adapting heart failure guidelines for resource-limited settings: A European Journal of Heart Failure expert consensus document

Abstract

Heart failure (HF) remains a leading cause of morbidity and mortality worldwide, with particularly poor outcomes in low- and middle-income countries (LMICs). Despite strong evidence for guideline-directed medical therapy in terms of mortality/morbidity reduction and improvement in quality of life, the real-world implementation remains suboptimal, even in high-income settings. In LMICs, barriers are compounded by limited access to diagnostics, essential pharmaceutical and device therapy, alongside socioeconomic constraints and fragmented healthcare systems. Structural inequities, including the underrepresentation of LMIC populations in clinical trials, further restrict the applicability of evidence-based interventions. This position document highlights key challenges to guideline implementation in resource-limited settings, including affordability, workforce shortages, cultural practices, and gaps in infrastructure and insurance coverage. Strategies to address these barriers include the use of accessible diagnostics, decentralization of care, expanded roles for non-specialist providers, and telemedicine-supported continuity of care. Broader systemic reforms, including improved insurance systems, stronger referral networks and the integration of primary prevention, are critical. Finally, equitable representation of LMIC populations in clinical research should be prioritized to ensure the safety and efficacy of future therapies. Bridging the gaps in HF care at the global level requires context-specific adaptation of international guidelines, targeted healthcare system strengthening, and innovative care delivery models that make evidence-based HF treatment accessible, affordable, and sustainable.