From the Guidelines
Guideline-Directed Medical Therapy (GDMT) for heart failure primarily includes four main medication classes: ACE inhibitors or ARBs (or the newer ARNIs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors, as recommended by the most recent guidelines 1. The medications included in GDMT for heart failure are:
- ACE inhibitors or ARBs (or the newer ARNIs)
- Beta-blockers
- Mineralocorticoid receptor antagonists (MRAs)
- SGLT2 inhibitors For patients with heart failure with reduced ejection fraction (HFrEF), first-line medications include:
- ACE inhibitors such as lisinopril (10-40 mg daily) or enalapril (2.5-20 mg twice daily), or ARNIs like sacubitril/valsartan (24/26 mg to 97/103 mg twice daily) 1
- Beta-blockers are essential, with evidence-based options including carvedilol (3.125-25 mg twice daily), metoprolol succinate (12.5-200 mg daily), or bisoprolol (1.25-10 mg daily) 1
- MRAs like spironolactone (12.5-50 mg daily) or eplerenone (25-50 mg daily) should be added for most patients with HFrEF 1
- SGLT2 inhibitors such as dapagliflozin (10 mg daily) or empagliflozin (10 mg daily) have shown significant benefits regardless of diabetes status 1 The use of these medications has been shown to reduce cardiac workload, inhibit harmful neurohormonal activation, prevent cardiac remodeling, and improve survival, with quadruple medical therapy for HFrEF estimated to reduce the risk of death by 73% over 2 years 1. Medication initiation typically involves starting at low doses with gradual titration while monitoring blood pressure, heart rate, renal function, and electrolytes. Key considerations for implementing GDMT include in-hospital initiation, simultaneous or rapid sequence initiation, participation in quality improvement registries, multidisciplinary titration clinics, virtual consult teams, reduction of cost-sharing, remote algorithm-based medication optimization, electronic health record-based interventions, and direct-to-patient educational initiatives 1.
From the FDA Drug Label
Sacubitril and valsartan tablets are a combination of sacubitril, a neprilisin inhibitor, and valsartan, an angiotensin II receptor blocker, and is indicated: to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure and reduced ejection fraction. Ivabradine is a hyperpolarization-activated cyclic nucleotide-gated channel blocker indicated: • To reduce the risk of hospitalization for worsening heart failure in adult patients with stable, symptomatic chronic heart failure with reduced left ventricular ejection fraction. Valsartan tablets has been evaluated for safety in 290 pediatric patients aged 1 to less than 6 years and over 400 patients aged 6 to 17 years No relevant differences were identified between the adverse experience profile for pediatric patients and that previously reported for adult patients.
The medications that are part of Guideline-Directed Medical Therapy (GDMT) for heart failure include:
- Sacubitril and valsartan to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure and reduced ejection fraction 2
- Ivabradine to reduce the risk of hospitalization for worsening heart failure in adult patients with stable, symptomatic chronic heart failure with reduced left ventricular ejection fraction 3
- Valsartan for the treatment of heart failure 4
From the Research
Guideline-Directed Medical Therapy (GDMT) for Heart Failure
The medications that are part of GDMT for heart failure with reduced ejection fraction (HFrEF) include:
- Renin-angiotensin system inhibitors 5, 6, 7, 8
- Evidence-based β-blockers 5, 6, 7, 8
- Mineralocorticoid inhibitors 5, 6, 9, 7
- Sodium glucose cotransporter 2 inhibitors 5, 9
Specific Medications
Some specific medications that are part of GDMT include:
- Beta-blockers such as metoprolol succinate, carvedilol, and bisoprolol 6
- Angiotensin converting enzyme inhibitors (ACEis) 6, 7, 8
- Angiotensin receptor blockers (ARBs) 6, 7, 8
- Angiotensin receptor neprilysin inhibitors (ARNIs) 6, 7
- Mineralocorticoid receptor antagonists (MRAs) 6, 9, 7
Importance of GDMT
GDMT has been shown to improve clinical outcomes in patients with HFrEF, including reduced mortality and hospitalizations 5, 6, 7, 8. However, there is often underutilization of GDMT, which can be due to various factors such as lack of awareness and clinical inertia 7.