Identifying and overcoming barriers to referral in advanced heart failure. A scientific statement of the Heart Failure Association (HFA) of the ESC.

The identification of patients with advanced heart failure (HF) remains challenging, often leading to delayed referrals and suboptimal use of advanced therapies such as long-term mechanical circulatory support (MCS) or heart transplantation (HT). This delay contributes to worse outcomes and missed opportunities for timely intervention. Many eligible patients are not recognized early enough in their clinical trajectory, either due to the complexity of the condition, overlapping HF phenotypes, or limited awareness of referral criteria among non-specialist clinicians. In this context, the aim of this scientific statement from the Heart Failure Association (HFA) of the ESC is to systematically identify and address the multifaceted barriers that hinder early recognition and referral for advanced HF care. These barriers span across different stakeholders-patients, caregivers, referring physicians, HF specialists, the academic community, and health authorities. The document proposes practical, stakeholder-specific solutions to improve awareness, standardize referral criteria, integrate digital decision-support tools, and structure care networks. Ultimately, the goal is to enable earlier access to specialized evaluation, ensure equitable use of HT and MCS when appropriate, and improve both survival and quality of life for patients living with advanced HF.