Guideline-Directed Medical Therapy (GDMT) for HFrEF: The Four Pillars
Guideline-Directed Medical Therapy (GDMT) for HFrEF: The Four Pillars
• All symptomatic HFrEF patients should receive the four foundational therapies as early as possible, starting with low doses and uptitrating in parallel to the target or maximally tolerated dose.
1. Renin–Angiotensin System Inhibitor / ARNI
• Sacubitril/valsartan : 24/26mg (50mg tab)or 49/51mg(100mg tab) bid → 97/103 mg (200mg tab)bid (preferred).
• If ARNI is not used:
* Candesartan: 4 → 32 mg daily.
* Losartan: 50 → 150 mg daily.
* Valsartan: 40 mg bid → 160 mg bid (unlike its once-daily use in hypertension).
• Increase dose every ≥2 weeks; monitor blood pressure, renal function, and electrolytes.
• Allow a 36-hour washout when switching from an ACE inhibitor to ARNI.
2. Evidence-Based Beta-Blockers
• Bisoprolol: 1.25 → 10 mg daily.
• Carvedilol: 3.125 mg bid → 25 mg bid (50 mg bid if >85 kg).
• Nebivolol: 1.25 → 10 mg daily.
• Start only in stable, euvolemic patients and uptitrate every ≥2 weeks.
3. Mineralocorticoid Receptor Antagonists (MRA)
• Spironolactone: 25 → 50 mg daily.
• Eplerenone: 25 → 50 mg daily.
• Frail or elderly patients may start at 12.5 mg daily.
• Increase after 4–8 weeks; monitor potassium and renal function.
• Avoid initiation if eGFR <30 mL/min/1.73 m² or K⁺ >5.0 mmol/L.
4. SGLT2 Inhibitors
• Dapagliflozin: 10 mg daily.
• Empagliflozin: 10 mg daily.
• Starting dose = target dose; no titration required.
• Avoid use in eGFR <20 mL/min/1.73 m², SBP <95 mmHg, pregnancy, or type 1 diabetes.
Key Message
• Start all four pillars early and uptitrate together, rather than maximizing one drug before introducing the others, while closely monitoring blood pressure, heart rate, renal function, and serum potassium.
Source: Medscape
https://emedicine.medscape.com/article/163062-overview
