Heart Failure Measurement and Care Gaps

Evidence

Heart-failure research often focuses on finding a better signal or delivering established care more consistently. Two July studies examined those distinct problems. One asked whether left-ventricular activation time (LVAT), measured from a standard electrocardiogram, was associated with outcomes after cardiac resynchronization therapy (CRT). The other evaluated a dashboard-directed clinic designed to identify medication gaps among Veterans with heart failure. Both reported favorable signals, but the endpoints and evidentiary strength were very different.

The CRT study retrospectively analyzed 415 recipients treated at a high-volume Swedish tertiary center. Median age was 72.8 years, 77.3% were men, median baseline left-ventricular ejection fraction was 27.5%, and median follow-up was 2.8 years. Investigators defined LVAT as the interval from QRS onset to the largest deflection in electrocardiogram lead V6. The primary endpoint combined heart-failure hospitalization and all-cause mortality; 171 participants reached that endpoint.

Among 389 participants with left bundle-branch block or nonspecific intraventricular conduction delay, each 10-millisecond increase in baseline LVAT was associated with a lower unadjusted endpoint rate (hazard ratio 0.92, 95% confidence interval 0.86–0.99; p=0.026). After adjustment for clinical factors, the estimate weakened and crossed the null (hazard ratio 0.93, 95% confidence interval 0.85–1.01; p=0.086). Post-implant LVAT was not associated with the endpoint, and the authors reported that LVAT did not outperform QRS duration, the established electrical timing measure. The result therefore describes an observational association, not a validated selection rule.

The dashboard study followed a different path. At one Veterans Affairs center, cardiology fellows and nurse practitioners used a heart-failure dashboard during a weekly half-day clinic from July 2024 through June 2025. They reviewed records for gaps in guideline-directed medical therapy, conducted targeted telehealth contacts, and coordinated follow-up. Of 163 patients receiving the intervention, 128 had heart failure with reduced ejection fraction and 150 were not receiving a sodium-glucose cotransporter 2 inhibitor when identified by the workflow.

Therapy was initiated by telephone or recommended for initiation in 79 patients. Among 107 patients considered eligible for medication optimization, the mean composite optimization score increased from 2.10 to 2.81 (p=0.018). The component score for sodium-glucose cotransporter 2 inhibitor therapy increased from 0.40 to 0.74 (p=0.013). These are medication-process measures, not evidence of fewer hospitalizations, longer survival, or better symptoms. The abstract describes a single-center implementation study without a concurrent control group.

Read side by side, the studies locate uncertainty at two points in the research-to-care chain. The CRT study tests whether an additional physiological measurement can distinguish outcomes beyond existing clinical features. The dashboard study tests whether an organized workflow can change a recorded care process. One signal became statistically uncertain after adjustment; the other moved a process score but did not measure a patient-centered clinical benefit.

Analysis — The measurement-to-action divide

This cross-study connection is analysis, not an established clinical conclusion. Heart-failure systems can fail because available measurements do not isolate who is most likely to experience an outcome, or because known care gaps remain invisible and unaddressed in routine workflows. The LVAT study sits on the first side of that divide: its unadjusted association suggests possible prognostic information, but confounding and comparison with QRS duration limit any claim of added value. The dashboard study sits on the second side: it demonstrates that a structured team can find and act on medication gaps, but its before-and-after process scores cannot separate the dashboard's effect from selection, time trends, clinician attention, or other parts of the bundled clinic. Together, the studies suggest an emerging research direction: evaluation should follow a measurement from discrimination, through workflow uptake, to patient-centered outcomes. That sequence has not been established here, and the two interventions should not be treated as parts of one proven pathway.

Limitations

Both studies were observational and single-center. The CRT cohort was retrospective, mostly male, and drawn from an experienced tertiary center. Selection, referral, attrition, residual confounding, heterogeneous post-implant measurements, unavailable lead-position details, and small electrical-morphology subgroups constrain generalizability. Its adjusted LVAT estimate included no association, and LVAT did not outperform QRS duration.

The dashboard evidence available for this briefing was limited to the PubMed abstract. The study lacked a concurrent comparator, combined several workflow components, focused largely on one medication class, and reported process scores rather than clinical outcomes. Veterans at one center may not represent other heart-failure populations or health systems. Medication initiation and recommendation were also combined in one reported count. Neither study establishes that using its measurement or workflow changes an individual's prognosis. Multicenter prospective studies with prespecified comparators, external validation, implementation fidelity measures, and patient-centered endpoints would be needed to test the measurement-to-action hypothesis.