Treatment Gap in Very High-Risk Patients with Cardiorenal Disease: An Analysis of the Implementation of Evidence-Based Therapies

Abstract

Background: In patients with type 2 diabetes mellitus (T2DM) and cardiorenal disease, various therapies reduce cardiovascular and renal events. However, their implementation in clinical practice remains suboptimal. Objective: To quantify the treatment gap in patients with T2DM and very high-risk cardiorenal disease using a proportional index that differentiates between Class IA and IIA indications, and to evaluate associated clinical factors. Methods: An observational study based on data collected prospectively from the FERICODIAB registry. The study included 367 adults with T2DM and heart failure (HF) and/or chronic kidney disease (CKD). Therapeutic eligibility criteria were established according to international guidelines, and a weighted treatment gap index (prop-TGI), ranging from 0 (no treatment gap) to 1 (complete treatment gap), was developed. Associated factors were evaluated using multivariate linear regression and, as a sensitivity analysis, beta regression was performed. Results: The mean age was 70.0 ± 11.1 years; 61.6% were men, 80.7% had CKD, and 25.6% had HF. The mean TGI-IA was 0.491 (median: 0.483), and 45.4% had an TGI-IA >0.5. The mean TGI-IIA was 0.454 (median: 0.778), and 51.2% had an TGI-IIA >0.5. The largest gaps were observed for finerenone (98.5%), GLP-1 receptor agonists (84.4%), and the combinations of finerenone + SGLT2 inhibitors (97.7%) and SGLT2 inhibitors + GLP-1 receptor agonists (90.9%). Older age, higher body mass index, and female sex were associated with a larger treatment gap in the linear model, although the associations with age and female sex were no longer statistically significant in the beta regression model. Conclusion: There is a significant treatment gap between recommendations and their implementation, particularly for the most recent cardiorenal therapies and recommended combination therapies. Systematic and interdisciplinary strategies are needed to optimize their use.