Background: The 2023 ESC Heart Failure (HF) Guidelines recommend the rapid up-titration of guideline-directed medical therapy (GDMT) for all patients after HF hospitalisation. Real-world data on the implementation of a rapid up-titration programme (RTP) are scarce. Methods: We aimed to summarise the primary experiences of a six-week RTP in a multicentre observational study of five cardiology centres, evaluating the GDMT applied and the target doses (TDs) achieved during the RTP. The safety of RTP in relation to exceeding the “safety indicators” used in the STRONG-HF trial and any serious adverse events were observed. Changes in the left ventricular ejection fraction (LVEF) after RTP were evaluated. Results: Among the 90 consecutive patients (age: 56 [49–63] years, HFrEF: 96%, NT-proBNP at discharge: 1390 [735–2835] pg/mL; continuous variables are presented as median and interquartile ranges, while categorical variables are shown as absolute numbers and percentages, respectively), a remarkable proportion of patients received GDMT at hospital discharge; however, target doses were rarely achieved (RASi: 100%, TD RASi: 11%; βB: 97%, TD βB: 6%; MRA: 99%, TD MRA: 82%; SGLT2i: 98%, TD SGLT2i: 98%; triple therapy [TT: RASi + βB + MRA]: 96%, TD TT: 2%, quadruple therapy [QT: RASi + βB + MRA]: 94%, TD QT: 2%). After the six-week RTP, 100% of the total cohort (TC) were receiving RASi; 99–99–99% were receiving βB, MRA, and SGLT2i medications; and altogether, 98–98% were on TT and QT. In total, 78–78% of the patients received ≥50% of the TDs of TT and QT, while 51–51% of the TC were on TDs of TT and QT. During the RTP, no serious adverse events were observed. Between two and four months after the RTP, 51% of HFrEF patients evolved to the HFimpEF category. Conclusions: The present multicentre, observational study confirms that RTP is feasible and safe in real-world clinical practice, leading to a remarkably large proportion of patients receiving GDMT by the end of the six-week RTP, resulting in a significant increase in LVEF.

The diagnosis of Takotsubo syndrome may be challenging in daily clinical practice. Our patient presented with an initial diagnosis of acute anterolateral ST elevation myocardial infarction, while coronary angiography showed non-obstructive coronary arteries. Transthoracic echocardiography raised the suspicion of hypertrophic obstructive cardiomyopathy (HOCM) and Takotsubo syndrome. In such clinical presentations, cardiac MRI (cMRI) plays a crucial role in differential diagnosis as part of a multimodality imaging approach. For our patient, serial cMRI studies helped to establish the diagnosis of Takotsubo syndrome during the index presentation and confirmed it retrospectively; the presence of transient hypertrophic cardiomyopathy phenocopy and left ventricular outflow tract obstruction (LVOTO) was partially due to transient oedema in the active phase of the condition. In addition, cMRI proved to be a key modality for excluding HOCM as a potential alternative cause of the dynamic LVOTO. With the implementation of complex guideline-directed medical therapy, the patient improved to the heart failure with improved ejection fraction category with a remarkable improvement in clinical status.