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Optimization of guideline-directed medical therapy in chronic heart failure remains challenging in real-world practice, particularly outside settings with routine cardiopulmonary exercise testing. In this context, cardiovascular rehabilitation can improve functional capacity, symptoms, and quality of life, while structured follow-up may also facilitate treatment adjustment. We therefore evaluated whether exposure to a structured multimodal functional assessment pathway, embedded within a more intensive follow-up model, was associated with pharmacological optimization and functional change in chronic heart failure.

We conducted a retrospective, single-center cohort study including adults with chronic heart failure with reduced or mildly reduced ejection fraction managed in a tertiary university clinic. Patients were classified according to documented exposure to an integrated pathway that combined standardized 6 min walk testing, heart rate dynamics, oxygen saturation response, perceived exertion, validated quality-of-life assessment, and prespecified interim reassessment, versus usual care. The integrated pathway involved more frequent clinical contact than usual care. The primary outcome was change in 6 min walk distance over 6 months. Secondary outcomes included changes in heart rate recovery, oxygen saturation nadir, Borg perceived exertion score, quality-of-life score, intensity of guideline-directed medical therapy, treatment intensification rates, and heart failure hospitalization.

The study included 250 patients with comparable baseline demographic and clinical characteristics. Patients managed within the structured pathway showed greater improvement in 6 min walk distance at 6 months than those receiving usual care, together with more pronounced improvement in secondary functional parameters and quality-of-life scores. Pharmacological optimization, reflected by higher uptake and intensification of guideline-directed medical therapy, also occurred more frequently in the structured pathway group. The integrated group, however, also had higher follow-up intensity, which limits causal interpretation of the observed between-group differences.

In this real-world heart failure cohort, exposure to a structured care pathway combining repeated multimodal functional profiling with closer follow-up was associated with greater functional improvement and more intensive pharmacological optimization. These findings should be interpreted as pathway-level associations rather than proof that functional assessment alone drove benefit, and they require prospective validation.