Optimizing guideline-directed medical therapy for heart failure with reduced ejection fraction

Announcing a new article publication for Cardiovascular Innovations and Applications journal. Over the past several decades, major strides have been made in the management of heart failure with reduced ejection fraction (HFrEF). The 2022 AHA/ACC/HFSA guidelines recommend four drug classes in all patients with symptomatic HFrEF.

This guideline directed therapy (GDMT) includes renin angiotensin receptor (RAAS) blockade, preferentially with angiotensin receptor neprilysin inhibitors (ARNI), beta blockers, mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter inhibitors (SGLT2i). An optimal GDMT regimen has been estimated to achieve greater than 70% mortality benefit. Unfortunately, most patients with HFrEF are not taking the appropriate medications or doses. Several clinical challenges and questions arise when attempting to initiate and titrate these medications. Although the guidelines offer several suggestions for this process, each patient's hemodynamic profile varies markedly, thus making development of a uniform algorithm difficult.

As new trials are performed, greater emphasis is being placed on more aggressive titration of GDMT. Most importantly, initiation of GDMT should start during hospitalization and continue with close outpatient follow-up. Identifying each patient profile, defined by volume status, blood pressure, heart rate, and kidney function, dictates the order and timing of GDMT titration.