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5mo
GDMT Optimization: A High-Intensity Care for Heart Failure

Guideline-directed medical therapy (GDMT) is essential in heart failure (HF) management, improving patient outcomes and survival by targeting key pathways in HF progression, stabilizing the disease, and enhancing quality of life. High-intensity care optimizes GDMT by ensuring recommended doses are achieved for maximum benefit.

Despite its efficacy, GDMT remains underutilized, increasing hospitalization and mortality risks. Full implementation of all four GDMT drug classes—ARNI, beta-blockers, MRAs, and SGLT2 inhibitors—could extend life expectancy, yet barriers persist. Clinical inertia delays treatment intensification, while physiological factors such as low blood pressure, renal issues, and electrolyte imbalances complicate therapy. Comorbidities require careful medication adjustments, and adherence is often challenged by regimen complexity, side effects, and socioeconomic factors like cost and limited healthcare access.

A multifaceted approach is key to overcoming these challenges. Digital health solutions, telemedicine, and remote monitoring improve adherence and prescription rates. Multidisciplinary care teams—including nurses, pharmacists, and mental health professionals—offer comprehensive support. Clinician education, treatment algorithms, and financial assistance programs further promote GDMT adoption.

SGLT2 inhibitors play a vital role in both HFrEF and HFpEF, providing cardiorenal benefits, reducing congestion, and lowering diuretic use. Their inclusion strengthens HF management, making them essential in modern treatment strategies.

What strategies do you use to overcome clinical inertia in GDMT implementation? How do you address physiological limitations like renal function and low blood pressure when optimizing GDMT?

  • 5mo
    I usually start with low doses of coreg and entresto. Almost all patients are on a loop diuretic. if BP tolerates I add aldactone and SGLT2 next. If the patient is hospitalized I will have the patient stay in the hospital for 3 to 4 days in order to initiate all of the therapies. If the patient has low blood pressure I wait to start the aldactone and SGLT2 until the patient is seen in the office. I up titrate the coreg and entresto over the couple of months as the patient tolerates. I obtain labs daily in the hospital and on all office visits
  • 5mo
    The guidelines are based on very strong clinical research. I convey the results of the more well-known studies to patients so they can appreciate the value of ARNI, and SGLTis. Additionally, I discuss with patients the renal protective effects of dapa and empa.
    I suspect, as we become more familiar with GLP1 agonists, our prescriptions of semaglutide and similar drugs will increase as well.
  • 5mo
    I first express the importance of all of the GDMT medications to the patients even if they are not symptomatic. I like to initiate an ARNi and beta blocker with an SGLT2i. After I see how the blood pressure reacts in about a week I bring the patient back to the office and ad an MRA. I look to see if the patient develops symptomatic hypotension and use midodrine if needed. If Cr rises I would decrease the diuretic and make sure the patient is well hydrated. Would only adjust beta blocker if HR falls below 50 or the patient experiences severe fatigue. The other strategy I use is to ask the patient to take there medications at different times of the day to "spread out" the hypotensive affects.
  • 5mo
    There is no question from the data that quadruple therapy is imperative. One of the challenges that I have found in achieving quadruple therapy as well as appropriate dosing is that many patients are cared for by multiple caregivers. Often a patient may be seeing a cardiologist as well as their primary care, physician and nephrologist, and there are different goals of each of those caregivers.
    I have seen situations where either the primary care physician or a physician extender cut back on a patient medical regimen telling them that they didn’t need to be on several blood pressure medication’s or that their blood pressure was well enough controlled with a certain dose of beta blocker so there was no need to increase it.
    Part of the challenge is explaining to the patient and their pcp team that the regimen they are on is not for treatment of their blood pressure even though several of the medicines are given for blood pressure as well, but rather the goal is maximization of dose and completion of the four drug regimen in order to achieve maximum benefit and congestive heart failure
  • 5mo
    Generally speaking, I leverage our entire care team to address this question. Our APPs and clinical pharmacists are aware of the need to get patients on all four pillars of GDMT and help us to rapidly and appropriately initiate and titrate them. Additionally, we've partnered with an AI company to identify opportunities for improvement and are leveraging those insights to improve patient care.
  • 5mo
    For 20+ years my local community hospital has had some iteration of a post-hospital heart failure program, primarily RN-driven, which has consistently reduced readmission rates and improved outcomes across the board. To my mind, "clinical inertia" is equal parts physiologic barriers (hypotension, CKD), cost of drugs, and education/compliance/close monitoring in the early outpatient setting. The first is not really something we can change with systemic interventions, the second is on the drug and insurance companies, and the third is on whoever is responsible for carving out time for doctors, midlevels, nurses, and home health providers to be able to help juggle the overwhelming number of things a new heart failure patient has to manage.
  • 5mo
    For 20+ years my local community hospital has had some iteration of a post-hospital heart failure program, primarily RN-driven, which has consistently reduced readmission rates and improved outcomes across the board. To my mind, "clinical inertia" is equal parts physiologic barriers (hypotension, CKD), cost of drugs, and education/compliance/close monitoring in the early outpatient setting. The first is not really something we can change with systemic interventions, the second is on the drug and insurance companies, and the third is on whoever is responsible for carving out time for doctors, midlevels, nurses, and home health providers to be able to help juggle the overwhelming number of things a new heart failure patient has to manage.
  • 5mo
    First do no harm- that mantra in my mind is a significant impediment in optimizing goal directed therapy for chf
    If someone is doing well on low dose ace or arni and has borderline low BP there is hesitation to increase dose
    Likewise if someone is on an ace/ ARNI with borderline high potassium levels - there is a hesitation to add mra and worry further about raising potassium levels
    I think this fear among many cardiologists is one fact for lack of 4?pillar rx and optimization of such rx
  • 6mo
    Education is important in explaining the rationale for using. These patients may have high pill burden and cost. Also making sure they have close follow up to make sure not hypotetensive or developing renal insufficiency or hyperkalemia
  • 6mo
    Earlier utilization of the 4 pillars of HF treatment is crucial. Often the challenges are low BP, renal insufficiency, potassium levels that need to be addressed. Still HFpEF is difficult to manage, only proven therapy is SGLT-2 inhibitors. Home monitoring of daily weights, BP and Na intake and frequent BMP levels play a vital role. Sometimes addition of low dose Midodrine will help to address the issue of low BP along with spacing of the drugs 1-2 hours apart.
  • 6mo
    Alan Braverman
    May 1, 2025 T
    The utilization of GDMT in HFrEF requires individualization of approach that encompasses BP, renal function, potassium level and assistance from the patient on home BP monitoring and outpatient lab assessment after initiation and uptitration of medication. Importantly, price checking for affordability of medications impacts decision making for many patients.
  • 6mo
    The utilization of GDMT in HFrEF requires individualization of approach that encompasses BP, renal function, potassium level and assistance from the patient on home BP monitoring and outpatient lab assessment after initiation and uptitration of medication. Importantly, price checking for affordability of medications impacts decision making for many patients.
  • 6mo
    Usually these meds get started in the hospital when pt presents with CHF
    The 4 classes of drugs are only proven for systolic CHF. The pts are almost always on a loop diuretic with resulting hypokalemia so spirono is the easiest first add on to facilitate diuresis. SGLT2 is relatively easy to add on early as well since without significant contraindications. The hospital carries a half strength of the lowest Entresto dose so I will often use this with bo BP. Beta is my last add on, best when approaching euvolemia. If I can get all the drugs started in house, the case manager can shepherd them through insurance to check for potential issues at DC. Also it is easier to adjust dosages then start new meds once patient is seen in follow up as an outpatient
  • 6mo
    I like to initiate multiple therapies initially and then add others one by one. Major impediment is cost/insurance coverage of ARNI and SGLT2 inhibitors and side effects of medications. I frequently encounter comanagement with nephrology, and often MRA, ARNI and occasionally SGLT2 inhibitors are discontinued per nephrology due to rise in creatinine of I like to check BMP once on GDMT and occasionally at baseline. However I often do not have control over whether the patient sees nephrology or not. Most nephrologists in our area do not like to use SGLT2 inhibitors or ARNI therapy.
  • 6mo
    If hemodynamics allow, will at times start multiple agents at once, and plan for close follow up to include labs if appropriate. Always provide an explanation of rationale behind meds.
  • 6mo
    Usually use rapid initiation of therapies with SGLT2/BB/AceI quickly transition to MRA.
  • 6mo
    In patients with combinations of conditions of diabetes, CHF, or CKD (with GFR well above 25cc/min), I can recommend SGLT2 inhibitors empaglifozin or dapagliflozin as beneficial in improving outcomes for all these conditions. I reduce other med doses, particularly diuretic dose when starting a SGLT2 inhibitor to reduce the risk of hypotension and worsening CKD. I recommend that the patient check his BP at least once a day, weight daily, and report large changes to my office. I always check a BMP a week or two after starting SGLT2 inhibitor and usually every 3 months afterwards, to assure electrolytes and renal function remain stable and adjust meds as appropriate. I also check BMP for signs of metabolic acidosis which can occur with SGLT2 inhibitors.

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