Guideline Implementation and Quality of Care in Patients With Heart Failure: the TITRATE-HF Registry (TITRATE-HF)

SUMMARY Rationale: Quality of Care registries provide valuable insight in guideline adherence and implementation of guideline recommendations in routine clinical practice.

Objective: The overall aim of the project is to study the titration of guideline directed medical therapy (GDMT) according to the European Society of Cardiology (ESC) HF 2021 guideline recommendations for patients with heart failure (HF) reduced ejection fraction (HFrEF), and mildly reduced ejection fraction (HFmrEF).

Study design: The current study is a prospective multi-center national quality of care registry (longitudinal) of regular HF care (as given).

Study population: The study population consists of patients with heart failure (de novo HF, chronic HF and worsening HF). Study setting is outpatient or inpatient (during admission). Patient sample is set at a minimum of 4000 patients, but can be expanded during the course of the registry project.

Participating sites: all hospitals with dedicated HF outpatient clinic in the Netherlands can participate.

Data: aggregated data

Intervention: none / no

Main study parameters/endpoints: The main parameters of quality of HF care are the adherence to guideline recommendation in terms of percentage (%) drug prescription, percentage (%) target dose (order, speed) and reason not to adhere to the guideline (intolerance, side-effects, maximum tolerated dose). The main endpoints for prognosis are the number of HF related hospitalizations and all-cause mortality during follow-up.

Nature and extent of the burden and risks associated with participation, benefit and group relatedness: There is no risk in participation, no intervention and no active involvement of patients for specific activities in the study. The project is a registration of care as given (standard care) to the participating subject with heart failure.

Study Overview

• Status: Active, not recruiting
• Conditions: Heart Failure
• Intervention / Treatment: Other: no intervention, observational study

• Study Type: Observational
• Enrollment (Estimated): 4289

Contacts and Locations

Study Locations

• Netherlands
  • Zuid-Holland
    • Rotterdam, Zuid-Holland, Netherlands, 3015CE
      • Erasmus MC

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: N/A

• Sampling Method: Non-Probability Sample

Study Population

The current registry studies only patient with heart failure and an ejection fraction below 50%.

Type of heart failure patients

• Chronic heart failure
• Worsening heart failure
• De novo or newly-diagnosed heart failure

Description

Inclusion Criteria:

In order to be eligible to participate in this registry, a subject must meet all of the following criteria:

1. Written informed consent obtained from subject aged ≥18 years.
2. Diagnosis of heart failure according to the European Society of Cardiology 2021 guideline definitions. An eligible patient must also fulfil to the category definitions of de novo HF, chronic HF or worsening HF.
3. Subjects willing and able to comply with the follow-up of regular care at the outpatient clinic. Also, sites should continue regular care for an included subject for at least 1 year (with preferably the entire project) at their outpatient HF clinic in this quality of care project.

Informed Consent: As the current research is a patient file study (registry) without an intervention of any kind. The medical ethics review board has reviewed the study and the study is declared to be not subject to the Medical Research Involving Human Subjects Act. Although informed consent is not strictly necessary, we have decided to ask permission from the patient use to their data for scientific research and comply to privacy/general data protection regulations for scientific research as well as to consent with data-coupling with other official data sources for quality of care projects in the Netherlands.

Exclusion Criteria:

1. Subjects with a life expectancy <1 years due to comorbidities according to the treating physician.
2. Subjects who have had a major cardiovascular event (e.g., myocardial infarction, open heart surgery, stroke) within 2 months interacting with prescription or dosing of HF drugs.
3. Subjects with advanced heart failure (end-stage) scheduled for or likely to undergo heart-transplantation or ventricular assist device within 6 months of baseline visit.

Study Plan

How is the study designed?

Number of groups / cohorts

3

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Chronic heart failure; Patients with chronic HF at least 6 months after the initial HF diagnosis with are in stable condition, treated with HF medication (not necessarily all GDMT) and evaluated for an intrinsic cardiac defibrillator device if applicable.	Other: no intervention, observational study; no intervention, observational registry of the prescription of medical therapy according to the European Society of Cardiology Heart Failure guidelines (quality of care).
Worsening heart failure; Patient with established chronic heart failure which after a period of "stable" HF have experienced an hospital admission with necessity of iv. diuretics or urgent visit needing iv. diuretics. Patients can be included in inpatient / admitted setting or outpatient setting where drug changes during admission (GDMT uptitration) can be recorded. The index event of hospitalisation must be within 6 months prior to inclusion in the registry (retrospective).	Other: no intervention, observational study; no intervention, observational registry of the prescription of medical therapy according to the European Society of Cardiology Heart Failure guidelines (quality of care).
de novo heart failure; Patients with heart failure with reduced ejection fraction (ejection fraction <40% with diagnosis within 3 months of inclusion (de novo heart failure or newly-diagnosed HF) with no previous diagnosis of HF.	Other: no intervention, observational study; no intervention, observational registry of the prescription of medical therapy according to the European Society of Cardiology Heart Failure guidelines (quality of care).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Prescription level (percentage,%) and target dose (percentage, %) of guideline-directed medical therapy for HF	according to European Society of Cardiology guideline recommendations	anticipated follow-up is 5 years

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
All-cause mortality	Death	anticipated follow-up is 5 years
Hospital admission due to heart failure related event and/or urgent visit with necessity of furosemide iv.	Hospitalisation	anticipated follow-up is 5 years
Hospital admission due to non heart failure related event	Hospitalisation	anticipated follow-up is 5 years

Collaborators and Investigators

• Sponsor: Erasmus Medical Center
• Collaborators: Netherlands Heart Institute
• Investigators: Study Chair: Rudolf de Boer, Erasmus Medical Center

Publications and helpful links

General Publications

• Clephas PRD, Malgie J, Schaap J, Koudstaal S, Emans M, Linssen GCM, de Boer GA, van Heerebeek L, Borleffs CJW, Manintveld OC, van Empel V, van Wijk S, van den Heuvel M, da Fonseca C, Damman K, van Ramshorst J, van Kimmenade R, van de Ven ART, Tio RA, van Veghel D, Asselbergs FW, de Boer RA, van der Meer P, Greene SJ, Brunner-La Rocca HP, Brugts JJ. Guideline implementation, drug sequencing, and quality of care in heart failure: design and rationale of TITRATE-HF. ESC Heart Fail. 2024 Feb;11(1):550-559. doi: 10.1002/ehf2.14604. Epub 2023 Dec 8.

Study record dates

Study Major Dates

• Study Start (Actual): June 5, 2022
• Primary Completion (Estimated): February 1, 2029
• Study Completion (Estimated): April 1, 2029

Study Registration Dates

• First Submitted: April 17, 2024
• First Submitted That Met QC Criteria: April 22, 2024
• First Posted (Actual): April 26, 2024

Study Record Updates

• Last Update Posted (Estimated): August 15, 2025
• Last Update Submitted That Met QC Criteria: August 12, 2025
• Last Verified: August 1, 2025

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Cardiovascular Diseases; Heart Diseases; Heart Failure
• Other Study ID Numbers: MEC-2022-0252

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No