Nearly 25 years ago, the American Heart Association (AHA) and the American Stroke Association developed the Get With The Guidelines (GWTG) series1,2 to increase the consistent implementation of guidelines-based care in hospitals for patients with cardiovascular disease (CVD) and stroke.1-3

The GWTG suite of programs aims to improve patient care and outcomes through resources such as provider education, quality improvement measures, and patient registries, with an overarching goal of reducing death and disability associated with CVD and stroke.4,5  

For updates on the current status and achievements of the GWTG series, Cardiology Advisor interviewed AHA volunteer Gregg Fonarow, MD, FAHA, interim chief of the division of cardiology and the Eliot Corday Chair in Cardiovascular Medicine and Science at the University of California, Los Angeles (UCLA). Dr Fonarow is also director of the Ahmanson-UCLA Cardiomyopathy Center and co-director of the UCLA Preventative Cardiology Program.

How did the GWTG series come about? Why was there a need to create such a program in the various areas of focus, such as stroke and atrial fibrillation?

Dr Fonarow: In 1999, AHA volunteers identified a need to establish a mechanism by which hospitals could stay up to date with the latest clinical guidelines and recommendations to improve cardiovascular care quality and clinical outcomes. The AHA had set an ambitious goal to reduce death and disability due to CVD by 25% by 2010.1 With that goal in mind, AHA created the very first GWTG module for coronary artery disease, beginning with a regional pilot program. Based on this initial success, GWTG expanded nationally in 2001 and then launched additional modules.6

All GWTG [Get With the Guidelines] modules are associated with significant improvements in multiple processes of care strongly linked to improved outcomes.

This performance-improvement, registry-based approach would allow sites to evaluate their patient population against the most recent guideline-directed medical therapies, engage in collaborative learning, and share best practices. In addition to the technical support for the effort, AHA introduced the role of Quality Improvement consultants. Every GWTG hospital is provided a skilled quality consultant to assist as they use the registry to report on performance, identify opportunities for process improvement, and support their facility accreditation and certification with data from the registry. Sites also have the opportunity to be recognized by the AHA for their consistent performance. 


GWTG is now available for atrial fibrillation, coronary artery disease including chest pain, heart failure, stroke, and resuscitation to support cardiac arrest care.2 

Since the program’s inception, what have been some of the most significant achievements in terms of improved processes and outcomes at participating hospitals?

Dr Fonarow: All GWTG modules are associated with significant improvements in multiple processes of care strongly linked to improved outcomes. The AHA’s 2010 Strategic Goal was able to be met 3 years early, in 2007, in part based on GWTG.6

Currently, more than 2,600 US hospitals participate in one or more GWTG program module. That means nearly 80% of the American population has access to the program. Plus, since the creation of the program, more than 13 million US patient records have been entered into the registry.2 

A few of the most significant achievements include:

  • Demonstrating that participation in GWTG could reduce and even eliminate race/ethnicity- and sex-based disparities in the use of guideline recommended therapies. Equitable care provision during hospitalization has been achieved for most of the achievement measures targeted in GWTG modules.7,3
  • Learning that recognition, along with targeted quality improvement efforts, can drive adherence with the most recent clinical trial evidence and guidelines. An example was the development of the Target: Stroke program. The primary goal of this initiative was to reduce the door-to-needle times, as time to treatment is strongly associated with stroke outcomes. In just the first year of Target: Stroke, participating hospitals reduced the time from 80 minutes pre-intervention to 68 minutes, and patients experienced substantially improved clinical outcomes.8 In subsequent phases of the project, we have seen continued improvement and have now added Target: Stroke Advanced Therapy to evaluate and monitor interventional treatment. 
  • Integrating Target: Type 2 Diabetes in the Get With The Guidelines – Stroke, CAD, and HF modules, so we are caring across diagnoses.
  • Targeted implementation of the April 2022 Heart Failure guidelines in a pilot program that utilized Get With The Guidelines – Heart Failure. The emphasis was on the provision of quadruple therapy, which has increased the provision of guideline-directed medical therapies with participating sites from 14% to 49%. More importantly, the impacted patients had improvement in their LVEF [left ventricular ejection fraction]– moving from 9% at baseline to 55%.9         
  • Emphasizing systems of care for ST elevation myocardial infarction (STEMI). The GWTG-Coronary Artery Disease module meets the needs to measure and improve care from first medical contact – ie EMS or referring hospital – to reperfusion at the receiving center. Cohorts (eg, regions, states, and health systems) can use a Get With The Guidelines – Super User account to create data reports that drive performance as a group.   

What are the key factors driving the success of the GWTG programs?

Dr Fonarow: Understanding quality measurement is critical to improving patient care and making the certification process simple. Participating hospitals take their efforts a step further to ensure teams are using current guideline-directed treatments, setting best in class goals, and using peer benchmarks to compare performance. The integration of the most current guidelines is a key benefit to sites.  

Each participating hospital and health system works with a program consultant to implement, interpret data, identify areas for improvement, and articulate recommendations internally. It’s like having a consultant for the organization’s quality improvement objectives – and a significant reason these programs are so successful.

Also, the GWTG registry tool collects data from participating hospitals, allowing health care leaders and researchers to examine trends and continue bringing current evidence-based guidance to care delivery at hospitals across the country.

What are examples of situations in which deviation from the guidelines may be necessary – for example, due to access issues, limited resources, or patient-specific scenarios?        

Dr Fonarow: As with any therapy, there are contraindications to some treatments, and collecting information on contraindications is actually built into the registry. Sites are provided the opportunity to document the reason why a patient was excluded from the treatment and can use that information to evaluate overall treatment and considerations for process improvement. And of course, the final decision on treatment resides with the patient and their caregivers. They can decide against a treatment, and GWTG allows for that documentation. 

What areas are targeted for further development, and what are some of the program goals for the future?

Dr Fonarow: Until recently, the biggest gap in reaching all hospitals pertained to the small or rural hospital. These sites were less likely to join the quality improvement program due to resource limitations and low volumes of patients. However, the data shows these residents are at 30% higher risk of stroke, 40% more likely to develop heart disease, and live an average of 3 years fewer than urban counterparts.10 Yet, when rural hospitals did participate in GWTG, care quality improved, and in many cases performance rivaled that of urban hospitals. The AHA has now launched the Rural Community Network, which is open to all rural hospitals to join GWTG. This program aims to help close those gaps. More than 350 new hospitals have signed up so far.

As newer therapies are discovered, tested, proven to provide patient-centered outcomes, and are integrated into the national guidelines, these therapies can be rapidly integrated into GWTG. The program aims to further enhance these processes, so that each patient receives the best evidence-based care at the right time, at the right dose, equitably, reliably, every time. This is aligned with the AHA’s goal of advancing cardiovascular health for all, including identifying and removing barriers to health care access and quality.