What should be avoided in Guideline-Directed Medical Therapy (GDMT) for right-sided heart failure?

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Last updated: May 22, 2025 • View editorial policy

From the Guidelines

In right-sided heart failure, certain medications such as non-steroidal anti-inflammatory drugs (NSAIDs), class I anti-arrhythmic agents, calcium antagonists (verapamil, diltiazem), tricyclic anti-depressants, corticosteroids, and lithium should be avoided or used with caution due to their potential to worsen the condition. The management of right-sided heart failure should focus on treating the underlying cause, maintaining adequate preload, and using pulmonary vasodilators if pulmonary hypertension is present 1. High-dose diuretics should be used cautiously as excessive diuresis can reduce preload, which is needed for right ventricular function, potentially worsening cardiac output. Some key points to consider in the management of right-sided heart failure include:

  • Avoiding excessive fluid resuscitation and considering norepinephrine to maintain blood pressure 2
  • Using inotropes, such as dobutamine or milrinone, to address right ventricular failure 2
  • Decreasing pulmonary afterload with inhaled nitric oxide or inhaled/intravenous prostacyclin if indicated 2
  • Careful hemodynamic monitoring is essential when initiating any therapy in right-sided heart failure to prevent adverse outcomes. It is also important to note that certain guideline-directed medical therapies (GDMT) should be avoided or used with caution in right-sided heart failure, such as beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs), due to their potential to cause hypotension or worsen right ventricular function 3, 1.

From the Research

Right-Sided Heart Failure and GDMT

  • The use of Guideline-Directed Medical Therapy (GDMT) in right-sided heart failure is not as well-established as in left-sided heart failure, with limited data available on its effectiveness in this context 4, 5.
  • Right-sided heart failure often involves different pathophysiological mechanisms and treatment options compared to left-sided heart failure, making the extrapolation of GDMT used in left ventricular failure challenging 5.
  • The management of right-sided heart failure requires a comprehensive understanding of its epidemiology, pathophysiology, diagnosis, and treatment, including the role of tricuspid regurgitation and the potential benefits and risks of various therapeutic interventions 4.

Limitations and Challenges

  • The lack of clinical trials specifically examining right ventricular failure as a primary outcome limits the understanding of effective treatments for right-sided heart failure 5.
  • Low blood pressure and renal dysfunction, common comorbidities in heart failure patients, can pose significant challenges to the implementation of GDMT, highlighting the need for careful consideration and individualized treatment approaches 6.
  • Advanced heart failure, including right-sided heart failure, remains a major challenge, with a need for further research into effective medical management strategies, including the potential role of new therapeutic options and palliative care 7.

GDMT Use in Heart Failure

  • Studies have shown that GDMT use rates vary among heart failure patients, with certain populations, such as older patients and those with more comorbidities, being less likely to receive GDMT 8, 6.
  • The benefits of GDMT in heart failure patients with reduced ejection fraction, including those with low blood pressure and renal dysfunction, have been demonstrated, emphasizing the importance of optimizing medical therapy in these patients 6.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.