What Guideline-Directed Medical Therapy (GDMT) medication do you start with in a patient with decompensated Heart Failure with reduced Ejection Fraction (HFrEF)?

SGLT2 Inhibitors Should Be Started First in Decompensated Heart Failure

In patients with decompensated heart failure with reduced ejection fraction (HFrEF), SGLT2 inhibitors (dapagliflozin or empagliflozin) should be initiated first, as they have no blood pressure, heart rate, or potassium effects and can be safely started even during acute decompensation once hemodynamic stabilization is achieved. 1, 2

Rationale for SGLT2 Inhibitors in Acute Decompensation

• SGLT2 inhibitors are uniquely suited for early initiation because they do not lower blood pressure, do not affect heart rate, and require no dose titration, making them the safest GDMT medication to start in hemodynamically vulnerable patients 1, 2

• These agents provide rapid clinical benefits within weeks of initiation, independent of background therapy, and are effective even with moderate kidney dysfunction (eGFR ≥30 ml/min/1.73 m² for empagliflozin, ≥20 ml/min/1.73 m² for dapagliflozin) 2, 3

• In the acute decompensated setting, SGLT2 inhibitors should be initiated after ≥24 hours of hemodynamic stabilization with adequate organ perfusion 3

Sequential Medication Initiation Strategy

Step 1: Immediate Initiation (After Stabilization)

• Start SGLT2 inhibitor first at full dose (no titration needed) 1, 2
• Add mineralocorticoid receptor antagonist (MRA) at low dose if eGFR >25-30 ml/min/1.73 m² and potassium <5.0 mEq/L, as MRAs also have minimal blood pressure effects 1

Step 2: Add Heart Rate Control (If Needed)

• Initiate low-dose beta-blocker if heart rate >70 bpm and patient tolerates it hemodynamically 1
• Consider selective β₁ receptor blockers (metoprolol or bisoprolol) over carvedilol due to lesser blood pressure-lowering effect 1
• If beta-blockers cannot be tolerated and patient is in sinus rhythm, ivabradine may be used as an alternative for heart rate control 1, 4

Step 3: Add Renin-Angiotensin System Inhibition

• Initiate very low-dose ARNI (sacubitril/valsartan 25 mg twice daily) after ensuring adequate blood pressure 1
• If ARNI not tolerated, shift to low-dose ACEi or ARB 1
• Strict 36-hour washout period required when switching from ACE inhibitor to ARNI to avoid angioedema 2

Critical Safety Considerations

Blood Pressure Management

• Asymptomatic low blood pressure should not prevent GDMT initiation - patients with adequate perfusion can tolerate systolic BP 80-100 mmHg 1, 3
• Symptomatic hypotension (dizziness, fatigue) can usually be managed through patient education and spacing out medications rather than discontinuing therapy 1
• Reduce diuretics first if low blood pressure occurs in the absence of congestion, rather than stopping foundational GDMT 1

Monitoring Parameters

• Check blood pressure, renal function, and electrolytes 1-2 weeks after each medication adjustment 2, 3
• Modest creatinine increases (up to 30% above baseline) are acceptable and should not prompt GDMT discontinuation 3
• Monitor for hyperkalemia when using MRAs, especially with concurrent ACEi/ARB/ARNI 1

Evidence from Acute Decompensation Trials

• The PIONEER-HF trial demonstrated that sacubitril-valsartan initiated during hospitalization for acute decompensated heart failure led to greater NT-proBNP reduction than enalapril (46.7% vs. 25.3% reduction), with benefits evident as early as week 1, and no significant differences in rates of worsening renal function, hyperkalemia, symptomatic hypotension, or angioedema 5

• The PARAGLIDE-HF trial showed that sacubitril-valsartan initiated within 30 days of a worsening heart failure event in patients with EF >40% led to greater NT-proBNP reduction (ratio 0.85) and reduced worsening renal function, though with increased symptomatic hypotension 6

Common Pitfalls to Avoid

• Do not delay GDMT initiation waiting for "perfect" hemodynamics - even patients with low blood pressure benefit from SGLT2 inhibitors and MRAs 1, 2

• Do not discontinue all GDMT if hypotension occurs - instead, reduce diuretics first, then selectively adjust individual medications based on clinical profile 1

• Do not withhold SGLT2 inhibitors due to concerns about kidney function - they are safe and beneficial even with moderate renal dysfunction 2, 3

• Avoid excessive diuresis which can lead to hypotension and impair tolerance of other heart failure medications 3

• Continue preexisting GDMT during hospitalization unless hemodynamically unstable or contraindicated, as continuation is associated with lower risk of post-discharge death and readmission 3