What is the guideline-directed management (GDMT) for heart failure with reduced ejection fraction (HFrEF) in a patient on dialysis?

GDMT for Heart Failure with Reduced EF in Patients on Dialysis

For patients with heart failure with reduced ejection fraction (HFrEF) on dialysis, guideline-directed medical therapy (GDMT) should include beta-blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors as first-line agents, with cautious use of ACE inhibitors/ARBs/ARNi due to hemodynamic concerns.

First-Line Medications for HFrEF in Dialysis Patients

Beta-Blockers

• Beta-blockers are well-tolerated in dialysis patients and should be initiated at low doses
• Metoprolol succinate is preferred with a starting dose of 12.5-25 mg daily, gradually titrated to target dose of 200 mg daily as tolerated 1
• Monitor for bradycardia and hypotension, particularly during dialysis sessions
• Continue beta-blockers during hospitalization unless there is hemodynamic instability 2

Mineralocorticoid Receptor Antagonists (MRAs)

• MRAs have minimal effect on blood pressure and may actually increase BP in patients with low baseline BP 2
• Start with spironolactone 12.5-25 mg daily
• Monitor potassium levels closely, especially after dialysis sessions
• Consider as a preferred agent due to minimal hemodynamic effects 2

SGLT2 Inhibitors

• SGLT2 inhibitors have minimal effect on blood pressure and may be better tolerated in dialysis patients 2
• Dapagliflozin 10 mg daily or empagliflozin 10 mg daily
• Monitor for volume depletion, especially on dialysis days
• May improve outcomes with minimal hemodynamic compromise 2

Second-Line Medications (Use with Caution)

ACE Inhibitors/ARBs/ARNi

• Use with caution due to risk of hypotension, especially during dialysis
• Consider lower starting doses (e.g., lisinopril 2.5 mg daily) 3
• Monitor blood pressure closely before and after dialysis sessions
• May need to hold doses on dialysis days if hypotension occurs

Dialysis-Specific Considerations

Volume Management

• Optimize dry weight assessment to avoid volume overload while preventing intradialytic hypotension
• Consider more frequent or longer duration hemodialysis sessions to allow for slower ultrafiltration rates 4
• Peritoneal dialysis may be better tolerated in HFrEF patients due to more gradual fluid removal 4, 5

Medication Timing

• Consider administering blood pressure-lowering medications after dialysis rather than before to minimize intradialytic hypotension
• For patients with significant hypotension (systolic BP <80 mmHg), temporarily reduce or discontinue GDMT until BP improves 2

Monitoring and Follow-up

• Monitor blood pressure, heart rate, and volume status at each dialysis session
• Assess for symptoms of hypotension or orthostatic hypotension regularly 2
• Repeat echocardiography at 3-6 months to assess response to therapy
• Evaluate for device therapy (ICD/CRT) if LVEF remains ≤35% despite optimal medical therapy for 3-6 months 6

Common Pitfalls and Caveats

• Avoid excessive concern about hypotension: Asymptomatic or mildly symptomatic low BP should not be a reason for GDMT reduction or cessation 2
• Medication sequencing: When discontinuation or reduction of therapy is needed due to hypotension, start with the least tolerated medication 2
• Reinitiation strategy: When BP improves, always consider reinitiation of medications, starting with better-tolerated agents first 2
• Undertreatment risk: Despite limited evidence, complete avoidance of GDMT in dialysis patients with HFrEF leads to poor outcomes 7
• Hemodynamic monitoring: Pay special attention to pre-dialysis and post-dialysis blood pressure trends rather than isolated readings

Special Considerations

• Patients with HFrEF on dialysis have significantly worse prognosis than those with preserved EF, highlighting the importance of optimal GDMT despite challenges 8
• Only about 27% of dialysis patients with HFrEF receive the combination of a beta-blocker and RAAS inhibitor, indicating significant undertreatment 7
• When initiating beta-blocker therapy during hospitalization, wait until after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents 2

By following this approach to GDMT in dialysis patients with HFrEF, clinicians can optimize heart failure management while minimizing adverse effects related to dialysis and kidney failure.