Heart Failure Guideline-Directed Medical Therapy Scoring Systems: A Scoping Review

BACKGROUND: Guideline-directed medical therapy (GDMT) is central to the care of heart failure with reduced ejection fraction, yet no standard metric exists to quantify its implementation. METHODS: We conducted a scoping review to catalogue and characterize all published heart failure GDMT scores and summarize their application in clinical studies. We searched MEDLINE, Embase, the Central Register of Controlled Trials (CENTRAL), and Web of Science from October 2020 to March 2025. RESULTS: From 544 records, we included 26 studies (19 cohorts, 7 randomized trials; 354 281 patients). Of the 26 studies, 25 (96%) utilized different scores, including 13 adaptations of the Optimal Medical Therapy score originally proposed by the Heart Failure Collaboratory in 2020. All counted RASi (renin-angiotensin system inhibitors), beta-blockers, and mineralocorticoid receptor antagonists; 18 separated sacubitril-valsartan from other RASi, 15 incorporated sodium-glucose cotransporter-2 inhibitors, and 8 captured additional drug classes. Only 2 scores were adjusted for contraindications or intolerance. Across studies, GDMT scores served as a descriptor (N=14), covariate (N=11), predictor of future outcomes (N=12), and end point for GDMT optimization interventions (N=8). CONCLUSIONS: Multiple, disparate scores have been developed to quantify heart failure with reduced ejection fraction GDMT optimization, undermining the original intent. Key gaps in scores include heterogeneous weighting of drug classes and doses, minimal incorporation of intolerance to identify maximum-tolerated therapy, and heterogeneous incorporation of therapies beyond quadruple therapy. Future studies should focus on clear reporting and justification of the selected GDMT score, and the use of existing scores that incorporate relevant contemporary agents.