The 2025 ESC scientific statement on adherence

The 2025 ESC scientific statement on adherence to guideline-directed medical treatments in heart failure (DOI: 10.1002/ejhf.70090) primary focus on validated tools appears in Box 1 (“Practical tools for measuring adherence”), which lists a small set of practical, evidence-based options suitable for clinical practice and research in HF populations. These are intended to help identify non-adherence overall and uncover potential barriers across dimensions, rather than being dimension-specific:

1. ​Morisky Medication Adherence Scale (MMAS-8)
2. European Heart Failure Self-care Behaviour Scale (EHFScB-9)
3. Pharmacy refill data

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ESC recommends addressing each of the six dimensions:
​• Patient-related factors (e.g., beliefs, forgetfulness, low self-efficacy, depression/anxiety, cognitive impairment, age/sex differences):
Empower patients through structured education (≥3 face-to-face or home-based sessions, extended to caregivers) to build understanding of HF, medication rationale, and self-care skills. Promote shared decision-making and self-efficacy to foster ownership. Address mental health via integrated psychological support, as depression strongly predicts poorer adherence. Use simple tools like digital reminders/apps for forgetfulness and involve caregivers for elderly or cognitively impaired patients.
• Therapy-related factors (e.g., polypharmacy, complex regimens, side effects like hypotension/fatigue, frequent dosing):
Simplify treatment wherever possible—prioritize once-daily dosing, long half-life agents, or de-prescribing unnecessary drugs. Strongly advocate fixed-dose polypills (single-pill GDMT combinations) for stable patients after achieving target doses, which reduce pill burden, minimize confusion, and improve adherence by ~31% while lowering mortality risk by ~10% in cardiovascular settings. Routine medication reviews by pharmacists help manage side effects and up-titration tolerability.
• Condition-related factors (e.g., symptom severity, comorbidities like CKD/COPD/cognitive disorders, disease progression):
Tailor GDMT adjustments via multidisciplinary teams and remote monitoring to enhance tolerability amid comorbidities. Educate patients on linking symptom relief/improvement to therapy adherence for motivation. Involve specialists (e.g., geriatricians) and use real-time data from digital tools to adapt therapies proactively, reducing adverse reactions from polypharmacy.
• System-related factors (e.g., limited follow-up, fragmented care, provider overestimation of adherence, access barriers):
Embed routine adherence assessment (e.g., proportion of days covered <80% threshold, self-report tools like MMAS-8) into clinical workflows. Deploy multidisciplinary teams (nurses, pharmacists, specialists) for frequent contacts, education, up-titration support, and medication reconciliation—shown to boost adherence by 15–20%. Integrate digital ecosystems (text reminders, apps, remote monitoring like in the TIM-HF2 trial) for ongoing support and event reduction (up to 20–30% fewer HF events).
• Socioeconomic-related factors (e.g., financial constraints, low health literacy/education, insurance gaps):
Mitigate cost barriers through reduced co-payments, free medications where feasible, patient assistance programs, or affordable alternatives (e.g., ACEi/ARB when ARNi is unaffordable). Use simplified, culturally sensitive communication with visual aids for low-literacy groups. Screen for socioeconomic risks during assessments and advocate policy changes for better formulary access.
• Environmental-related factors (e.g., rural-urban access disparities, logistical challenges, social isolation, cultural/religious beliefs, language barriers):
Leverage community-based programs and digital solutions (apps, telehealth, text reminders) to overcome geographical isolation and improve access in underserved areas. Strengthen social support networks via caregiver/family involvement and culturally tailored education. Integrate mental health and social determinant screening, as these often amplify environmental barriers.

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