GDMT

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GDMT

- 4 pillars that reduce morbidity and mortality in HFrEF (EF ≤ 40%)

Class Beta- Blocker ARNI> ACEi / ARB MRA SGLT2i

Starting Dose Bisoprolol: 1.25mg daily Entresto: Sacubitril 49mg/ Valsartan Spironolactone: 12.5-25mg daily Empagliflozin: 10mg daily
Carvedilol: 3.125mg BID 51mg BID Eplerenone: 25mg daily Dapagliflozin: 10mg daily
Metoprolol Succinate: 12.5-25mg Lisinoprol: 2.5-5mg daily
daily Valsartan: 20-40mg BID

Target Dose Bisoprolol:10 mg daily Entresto: Sacubitril 97/103mg BID Spironolactone: 50mg daily (may be No target doses, but can consider
Carvedilol: ≤85kg → 25mg BID Lisinoprol: 20mg daily divided BID) increased dose if pt has uncontrolled
> 85kg → 50mg BID Valsartan: 160mg BID Eplerenone: 50mg daily DM
Metoprolol Succinate: 200mg daily

Contraindications Cardiogenic shock, heart block ACEi/Entresto: angioedema with eGFR <30, symptomatic eGFR <30, symptomatic hypotension
ACEi or ARB hypotension, hyperkalemia
Use of aliskiren
Use of concomitant Entresto or ACEi
within 36hrs of each other
Pregnancy

Adverse Effects Bradycardia, bronchospasm, fatigue, Cough (increased with ACEi), Gynecomastia (increased with spiro), Genital yeast infections, AKI, risk of
masking of hypoglycemia, hypotension, dizziness, hyperkalemia, GI sx (cramps, lower limb amputations
withdrawal if stopped abruptly hyperkalemia, angioedema diarrhea, ulcers, N/V)
(tachycardia, HTN, ischemia)

Monitoring BP, HR, BG, ECG BP, SCr, UOP, electrolytes (K) BP, SCr, UOP, electrolytes (K) BG, SCr, UOP

Pearls Carvedilol= nonselective (will have a Entresto has been shown to have Spironolactone is more affordable, *Proven mortality benefit in HFpEF
greater effect on BP) highest efficacy but has more mineralocorticoid
*Proven mortality benefit in HFpEF effects

Relative risk 31% ARNI: 28%, RAASi: 20% 25% 13%


reduction of
mortality

Trials CIBIS-II, MERIT-HF, COPERNICUS PARADIGM-HF (Entresto), RALEs, EMPHASIS-HF DAPA-HF, EMPEROR-Reduced,
PIONEER-HF CHIEF-HF
Recommended Hydralazine and Isosorbine dinitate in african american NYHA class III-IV with optimal GDMT to reduce morbidity and mortality

Initial dosing: 10/37.5mg TID → target: 40/75mg TID


ADRs: chest pain, HA, dizziness, weakness, hypotension

Goal: to start all 4 pillars and titrate up to target as tolerable


- Based on patient specific factors: BP, comorbidities
- Not recommended to discontinue these meds if a mild decrease in renal function or asymptomatic hypotension
- Reasonable to initiate agents in the hospital if clinically stable

Sources:
Heidenreich PA, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association
Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-e1032. doi: 10.1161/CIR.0000000000001063.
Lexicomp. Wolters Kluwer. 2023.
Dixit NM. Optimizing guideline-directed medical therapies for heart failure with reduced ejection fraction during hospitalization. Radcliffe Cardiology. July 3, 2021.
Accessed October 1, 2023. https://www.uscjournal.com/articles/optimizing-guideline-directed-medical-therapies-heart-failure-reduced-ejection-fraction.

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