From the Guidelines
Guideline-directed medical therapy (GDMT) for heart failure should include an ACE-I, a beta-blocker, and an MRA, with the option to replace ACE-I with an ARNI like sacubitril/valsartan, and addition of an SGLT2 inhibitor for patients with persistent symptoms, as recommended by the most recent guidelines 1. The cornerstone medications for GDMT in heart failure are:
- ACE inhibitors (like lisinopril 10-40mg daily) or ARBs (such as losartan 50-100mg daily), which reduce afterload and prevent cardiac remodeling
- Beta-blockers (carvedilol 3.125-25mg twice daily, metoprolol succinate 25-200mg daily, or bisoprolol 1.25-10mg daily) to reduce sympathetic stimulation
- Mineralocorticoid receptor antagonists (spironolactone 12.5-50mg daily or eplerenone 25-50mg daily) for patients with EF ≤35%
- SGLT2 inhibitors (dapagliflozin 10mg daily or empagliflozin 10mg daily) for patients with persistent symptoms, regardless of diabetes status
- Diuretics like furosemide (20-80mg daily or twice daily) for symptom relief, but not to improve mortality These medications should be initiated at low doses and titrated gradually while monitoring renal function, potassium levels, and blood pressure, as supported by the 2024 ESC guidelines for the management of chronic coronary syndromes 1. Key benefits of GDMT include:
- Reduced neurohormonal activation
- Decreased cardiac workload
- Improved ventricular remodeling
- Enhanced sodium and fluid excretion Collectively, these benefits improve cardiac function and patient outcomes, as emphasized by the European Society of Cardiology guidelines 1.
From the Research
Gdmt Heart Failure
- Gdmt is not explicitly mentioned in the provided studies, however, the studies discuss various treatments for heart failure with reduced ejection fraction (HFrEF) 2, 3, 4, 5, 6.
Treatment Options
- The use of diuretics to relieve symptoms and application of disease-modifying drug and device therapies are common treatment strategies for HFrEF 6.
- Patients with HFrEF should be treated with a β-blocker and one of an angiotensin receptor-neprilysin inhibitor, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker as foundational therapy 6.
- The addition of a mineralocorticoid receptor antagonist in patients with persistent symptoms is also recommended 6.
- Other treatments such as ivabradine, hydralazine/isosorbide dinitrate, sodium-glucose cotransporter 2 (SGLT2) inhibitors, and vericiguat may also be beneficial in certain patients with HFrEF 6.
Dosing Considerations
- The dosing of pharmacological therapy in heart failure is an important consideration, with studies suggesting that even low doses of foundational therapies can provide early benefits 2.
- However, achieving target doses of these therapies can be challenging due to factors such as blood pressure, renal function, and hyperkalaemia 3.
- The use of high doses of certain medications, such as lisinopril, has been shown to be effective in reducing the risk of major clinical events in patients with heart failure 5.