What is the approach to starting Guideline-Directed Medical Therapy (GDMT) for a newly diagnosed patient with decompensated heart failure (HF) admitted to the ward and on oxygen, and can it be initiated on day 1?

Approach to Starting GDMT in Newly Diagnosed Decompensated Heart Failure on Day 1

Yes, you should initiate GDMT during hospitalization once clinical stability is achieved after initial diuresis, and this can often begin on day 1 if the patient is adequately perfused and not requiring inotropes. 1

Initial Stabilization (Day 1 Priority)

Start IV loop diuretics immediately in the emergency department—do not delay. 2, 3 For a newly diagnosed patient not previously on diuretics, give 20-40 mg IV furosemide as the initial dose. 2 The primary goal is to restore euvolemia and relieve congestion, as residual congestion predicts worse outcomes. 1

Concurrent Assessment While Diuresing

While initiating diuretics, simultaneously assess:

• Adequacy of perfusion: Check for narrow pulse pressure, cool extremities, altered mentation, resting tachycardia 2
• Volume status: Jugular venous distention, peripheral edema, body weight 2, 3
• Precipitating factors: Acute coronary syndrome, arrhythmias, infections, medication non-adherence 3, 4

Monitor continuously: symptoms, urine output, vital signs, daily weights, and check serum electrolytes, BUN, and creatinine daily during IV diuretic use. 2

When to Start GDMT Components

Day 1 Initiation (If Stable)

SGLT2 inhibitors and MRAs should be started first because they have the least effect on blood pressure but rapid beneficial effects. 1 These can often be initiated on day 1 once adequate perfusion is confirmed and the patient is responding to diuretics. 1

Beta-Blockers: Timing is Critical

Do NOT start beta-blockers on day 1 if the patient required oxygen and is acutely decompensated. 1, 3

Beta-blocker initiation requires:

• Volume optimization achieved (no longer requiring IV diuretics) 1, 3
• Discontinuation of IV vasodilators and inotropes 3, 4
• Clinical stability (adequate perfusion, no signs of low output) 1

Start at a low dose only after these criteria are met, typically later in hospitalization or at discharge. 1, 3

ACE Inhibitors/ARBs/ARNIs: Cautious Approach

If the patient is on oxygen and newly diagnosed, delay ACE inhibitors/ARBs/ARNIs until:

• Volume status is optimized 1
• No marked azotemia or hyperkalemia risk 1
• Blood pressure is adequate (SBP >90-100 mmHg) 1

For patients with low blood pressure, consider starting very low dose sacubitril/valsartan (25 mg twice daily) after SGLT2i/MRA initiation, or use a low-dose ACE inhibitor if sacubitril/valsartan is not tolerated. 1

Practical Day-by-Day Algorithm

Day 1:

• IV loop diuretics immediately 2, 3
• Continue monitoring perfusion and volume status 2, 4
• Start SGLT2 inhibitor and MRA if adequately perfused, no contraindications 1
• Do NOT start beta-blockers or ACE inhibitors/ARBs/ARNIs yet 1, 3

Days 2-3:

• Continue IV diuretics, titrate based on response 2, 3
• Assess for clinical stability: improved congestion, stable renal function, adequate perfusion 1
• Consider low-dose ACE inhibitor/ARB/ARNI if blood pressure adequate and no worsening renal function 1

Days 3-5 (Before Discharge):

• Transition to oral diuretics when euvolemia approached 1
• Initiate low-dose beta-blocker only after IV therapies discontinued and volume optimized 1, 3
• Up-titrate GDMT cautiously one drug at a time using small increments 1

Critical Pitfalls to Avoid

Do not discontinue GDMT if mild renal function decrease or asymptomatic blood pressure reduction occurs—continue diuresis and GDMT unless contraindicated. 1 This is a common error that leads to suboptimal therapy.

Do not assume GDMT will be optimized after discharge—only 73% of eligible patients receive ACE inhibitors/ARBs/ARNIs, 66% receive beta-blockers, and 33% receive MRAs within 30 days post-hospitalization. 1 The hospitalization is your critical window to initiate therapy.

Do not start beta-blockers too early—this is associated with worse outcomes if initiated before volume optimization or while on inotropes. 1, 3

Special Considerations for Oxygen Requirement

A patient requiring oxygen suggests significant congestion and potentially compromised hemodynamics. Prioritize aggressive diuresis first 2, 3, then initiate GDMT components sequentially as clinical stability improves. 1 The oxygen requirement itself is not a contraindication to starting SGLT2 inhibitors or MRAs on day 1, but beta-blockers and renin-angiotensin system inhibitors should wait until more stable. 1, 3