Should GDMT be continued or stopped in a patient with ADHF?

Management of GDMT in Patients with ADHF

In patients with acute decompensated heart failure (ADHF) who are on guideline-directed medical therapy (GDMT), preexisting GDMT should be continued and optimized during hospitalization, unless specifically contraindicated. 1

Continuation of GDMT During ADHF Hospitalization

Evidence-Based Rationale

• Continuation of GDMT during hospitalization has been shown in registries to lower the risk of post-discharge death and readmission compared with discontinuation 1
• In the OPTIMIZE-HF registry, discontinuation of beta-blockers was associated with higher mortality compared to those continued on beta-blockers 1
• Withdrawal of ACEi/ARB among hospitalized patients with HFrEF was associated with higher rates of post-discharge mortality and readmission in the GWTG-HF registry 1

Specific Recommendations by Medication Class

1. Beta-blockers:

   • Continue in most patients with ADHF
   • Consider temporary withholding or dose reduction only in patients with:
     • Marked volume overload
     • Marginal/low cardiac output
     • Cardiogenic shock

2. ACEi/ARB/ARNi:

   • Continue during hospitalization
   • Do not routinely discontinue for mild decreases in renal function

3. Mineralocorticoid Receptor Antagonists (MRAs):

   • Continue unless severe hyperkalemia (>5.5 mEq/L) or acute kidney injury develops
   • May need temporary discontinuation if creatinine clearance <30 mL/min

4. SGLT2 inhibitors:

   • Can generally be continued during hospitalization for ADHF
   • Exception: If patient is undergoing surgery, should be held 3-4 days before procedure 1

When to Consider Temporary Discontinuation

Temporary discontinuation of GDMT may be necessary in specific circumstances:

1. Hemodynamic instability:

   • Cardiogenic shock
   • Symptomatic hypotension (systolic BP <90 mmHg)
   • Signs of hypoperfusion

2. Significant renal dysfunction:

   • Acute kidney injury with creatinine increase >0.5 mg/dL from baseline
   • Note: Mild increases in creatinine (up to 0.3 mg/dL) during decongestion should not prompt discontinuation 2

3. Severe electrolyte abnormalities:

   • Hyperkalemia >5.5 mEq/L (particularly with MRAs)

Management Algorithm During ADHF

1. Initial Assessment:

   • Evaluate hemodynamic status (blood pressure, heart rate, signs of hypoperfusion)
   • Review renal function and electrolytes
   • Assess volume status and congestion

2. Decision Framework:

   • If hemodynamically stable: Continue all GDMT components
   • If hypotensive but asymptomatic: Continue GDMT but monitor closely
   • If symptomatic hypotension or shock: Temporarily hold vasodilators (ACEi/ARB/ARNi) and consider reducing/holding beta-blockers

3. During Diuresis:

   • Monitor renal function and electrolytes daily
   • Do not routinely discontinue GDMT for mild decreases in renal function or asymptomatic reduction in blood pressure 1
   • Focus on achieving decongestion while maintaining GDMT

4. Before Discharge:

   • If GDMT was temporarily discontinued, reinitiate and optimize as soon as clinical stability is achieved 1
   • Ensure patient is on optimal doses of all appropriate GDMT components

Common Pitfalls to Avoid

1. Premature discontinuation of GDMT due to small increases in creatinine or asymptomatic hypotension

   • This is associated with worse outcomes 3

2. Failure to reinitiate GDMT before discharge if temporarily discontinued

   • Approximately 42% of patients are not prescribed GDMT within 30 days post-hospitalization 1

3. Discharging patients without optimizing GDMT

   • Hospitalization represents a critical opportunity to initiate and optimize therapy 1, 2

4. Overreaction to mild laboratory changes

   • Small increases in creatinine (up to 0.3 mg/dL) during decongestion are acceptable 2

Special Considerations

• Hypotensive symptoms may be due to over-diuresis, non-CV drugs with hemodynamic effects, or autonomic dysfunction - address these before reducing GDMT 1

• Worsening renal function: Consider using lower than target doses of ACEi/ARB/ARNi rather than complete discontinuation 1

• Diuretic therapy: Focus on achieving decongestion while maintaining GDMT; premature discontinuation of diuretics due to small increases in creatinine should be avoided 2

By following these evidence-based recommendations, clinicians can optimize outcomes for patients with ADHF while maintaining the mortality and morbidity benefits of GDMT.