A 64-year-old man with heart failure (HF) with reduced ejection fraction (25%) due to ischemic cardiomyopathy presents to the emergency department with acute decompensated HF. He is successfully treated with intravenous loop diuretics and achieves euvolemia. He is hemodynamically stable with renal function and electrolytes within reference ranges.
Prior to discharge, the clinician reviews his medications and considers optimization of his guideline-directed medical therapy (GDMT). He is currently on sacubitril/valsartan 24/26 mg twice daily and metoprolol succinate 25 mg daily.
The patient should start on a sodium-glucose cotransporter-2 inhibitor (SGLT2i) and mineralocorticoid-receptor antagonist (MRA) with plans for further titration of his regimen soon.
The correct answer is: Fact
The hospitalization is an opportune time to consider optimization of GDMT. Barring any contraindications, patients should be considered for initiation of quadruple therapy with sacubitril/valsartan, evidence-based beta-blocker, MRA, and SGT2i.1
Randomized controlled trials have proven the benefit of these medications and have shown that they often work synergistically to improve quality of life, prevent hospitalization, and improve survival.2 In addition, the STRONG-HF (Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies) trial showed that rapid initiation and uptitration of GDMT to maximally tolerated doses was associated with a reduction in symptoms, improved quality of life, and reduction in the risk of 180-day all-cause death or HF readmission.3
Educational grant support provided by: Boehringer Ingelheim Pharmaceuticals Inc. (BIPI) and Lilly USA, LLC (Lilly). To visit the course page for the Heart Failure & SGLT2is: The New Pillar in Care grant,click here!
Heidenreich PA, Bozkurt B, Aguilar D, 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. J Am Coll Cardiol 2022;79:e263-e421.
Greene SJ, Butler J, Fonarow GC. Simultaneous or rapid sequence initiation of quadruple medical therapy for heart failure-optimizing therapy with the need for speed. JAMA Cardiol 2021;6:743-44.
Mebazaa A, Davison B, Chioncel O, et al. Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial. Lancet 2022;400:1938-52.