Breaking Barriers in Heart Failure Care: The ESC’s Groundbreaking Statement on Medication Adherence and the Power of MMAS-8

Imagine a world where patients with heart failure (HF) could fully harness the life-saving potential of their prescribed treatments—reducing hospitalizations by up to 64% and slashing mortality risks. That’s the vision outlined in a pivotal new scientific statement from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) and the ESC Working Group on Cardiovascular Pharmacotherapy. Published online ahead of print in November 2025 in the European Journal of Heart Failure (DOI: 10.1002/ejhf.70090), this document doesn’t just highlight the problem; it charts a bold path forward, spotlighting tools like the 8-item Morisky Medication Adherence Scale (MMAS-8) as essential allies in the fight.

The Adherence Gap: Why It Matters More Than Ever At its core, the statement underscores adherence as the linchpin of GDMT success. In randomized controlled trials, these therapies shine, cutting cardiovascular mortality and HF hospitalizations by 64% across ejection fraction phenotypes, from reduced (HFrEF) to preserved (HFpEF). But step into routine practice, and the picture dims: Real-world persistence to triple therapy hovers at just 67% in Sweden and plummets to 5% in Norway. For ARNi in HFrEF, achieving a proportion of days covered (PDC) of ≥80% correlates with 31% fewer hospitalizations and 47% lower mortality at one year.
The stakes are personal. Non-adherence erodes quality of life, amplifies multimorbidity burdens, and widens disparities—women, the elderly, and those with low socioeconomic status or depression are hit hardest. Meta-analyses paint a hopeful counterpoint: Interventions boosting adherence can trim death risks by 2–11% and readmissions by 10–21%. As the statement aptly notes, bridging this efficacy-effectiveness gap isn’t optional; it’s imperative for equitable, patient-centered care.
Unpacking the Barriers: A Multidimensional Challenge
This ESC model closely aligns with the World Health Organization’s (WHO) established five dimensions of adherence—patient-related, therapy-related, condition-related, health care system-related, and social/economic factors—but innovatively expands it by adding an environmental dimension to account for logistical and geographical challenges that exacerbate disparities in treatment adherence. By addressing these multifaceted barriers holistically, the framework empowers clinicians to tailor interventions more effectively, ultimately improving outcomes in heart failure management.
Yet, recognition is the first step. By framing adherence as a modifiable determinant—independent of disease severity—the statement empowers clinicians to intervene proactively, much like we’d tackle cholesterol or blood pressure.
​Tools for Success: Enter the MMAS-8
Here’s where the statement truly innovates: It champions practical, scalable tools to measure and mitigate non-adherence, with the MMAS-8 earning a starring role. Listed prominently in Box 1 as a go-to self-report instrument, the MMAS-8 is hailed for its simplicity and low cost in chronic disease settings, including HF. Developed by Donald E. Morisky, this 8-question scale—seven yes/no items plus one 5-point Likert on difficulty remembering—delivers a score from 0 to 8. Higher scores signal better adherence (≥6 generally indicates good compliance), offering quick insights into behavioral patterns and barriers.
Why MMAS-8? It’s not flawless—it can overestimate adherence compared to objective measures like pharmacy refills or electronic monitors—but its utility shines in busy clinics. Validated across languages and populations, including a Vietnamese study of 180 chronic HF patients where it demonstrated strong reliability, the scale integrates seamlessly into routine assessments. As detailed on the official Morisky resource site (moriskyscale.com), MMAS-8 has been battle-tested in cardiovascular contexts, from hypertension to HF, with studies showing its predictive power for outcomes like reduced hospitalizations. In one Portuguese validation for HF outpatients, it correlated tightly with refill data, proving its edge in identifying at-risk patients early.
The statement’s endorsement isn’t casual; it positions MMAS-8 alongside metrics like PDC/MPR and the European Heart Failure Self-care Behaviour Scale (EHFScB-9), urging a hybrid approach. Combine it with simple queries (“Do side effects bother you?”) to uncover why patients skip doses, then tailor fixes—be it education, apps, or polypills that slash pill burdens by 31% in CV settings.

​Read the full statement here: https://doi.org/10.1002/ejhf.70090 License the MMAS-8 for clinical or research use: www.moriskyscale.com
#HeartFailure #Cardiology #MedicationAdherence #MMAS8 #ESCongress #GDMT #WHOAdherence
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