The study by Forte et al. on the treatment gap in patients with type 2 diabetes and cardiorenal disease deserves careful consideration, not only because of its findings but also because of what it implies for our daily practice. (1)

The key finding is a treatment gap exceeding 90%, in class IIa combinations such as gliflozins (SGLT2i) + GLP-1 receptor agonists (GLP-1 RA), or finerenone + SGLT2i, compared with gaps of less than 10% for renin-angiotensin-aldosterone system inhibitors (RAASi)—a finding that should not surprise us, but should certainly concern us. This aligns with the findings reported by Nelson et al. in the United States, where only 2.7% of eligible patients received the full recommended regimen, (2) and confirms that the problem lies not in the available evidence, but in its translation into daily practice.

What makes this study interesting is that it does not report usage rates therapy by therapy, but rather constructs a weighted index that ranks interventions according to their clinical importance. This reveals that the gap is not uniform: it is concentrated in the most recently introduced cardiorenal therapies, such as SGLT2 inhibitors, GLP-1 RA, and finerenone. Meanwhile, “classic” tools (statins, antiplatelet agents, RAASi) maintain acceptable penetration rates. This distinction is clinically relevant because it suggests that the obstacle is not a general reluctance to prescribe, but something more specific: inertia toward new treatments, uncertainty about who should initiate the medication, or a lack of awareness of updated guidelines.

This is where the article particularly challenges cardiologists. Dixon et al. had already documented that the prescribing of SGLT2i and GLP-1 RA varies significantly depending on the prescribing specialty, with lower utilization specifically in cardiology practices (3). If the cardiologist is, in many healthcare systems, the first or only specialized point of contact for patients with cardiorenal disease, delegating the initiation of these therapies to other specialties perpetuates the gap rather than reducing it.

Two secondary findings from the study deserve special attention in clinical practice: the wider gap observed in women and in older patients. Both patterns have been described previously—the first by Regensteiner et al. in their scientific statement for the American Heart Association, (4) and the second in Mc-Coy et al.’s analysis of Medicare Advantage beneficiaries (5)— and their replication in an Argentine cohort suggests that these are not local artifacts but rather systematic biases in the prescribing process, possibly linked to misperceptions of risk or tolerability rather than actual contraindications.

As a limitation, I agree with the authors themselves that the observational design precludes establishing causality, and that unmeasured variables—such as coverage, costs, and adherence—likely account for part of the gap. However, this does not detract from the practical message: having a reproducible index to audit one’s own practice and systematically incorporating an eligibility review for GLP-1 RA and finerenone into every consultation with a cardiorenal patient appears to be a concrete, low-cost step toward narrowing this gap between the guidelines and actual prescribing practices.