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Guideline-Directed Medical Therapy for the Treatment of Heart Failure with Reduced Ejection Fraction

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Abstract

Guideline-directed medical therapy (GDMT) is the cornerstone of pharmacological therapy for patients with heart failure with reduced ejection fraction (HFrEF) and consists of the four main drug classes: renin-angiotensin system inhibitors, evidence-based β-blockers, mineralocorticoid inhibitors and sodium glucose cotransporter 2 inhibitors. The recommendation for use of GDMT is based on the results of multiple major randomized controlled trials demonstrating improved clinical outcomes in patients with HFrEF who are maintained on this therapy. The effect is most beneficial when medications from the four main drug classes are used in conjunction. Despite this, there is an underutilization of GDMT, partially due to lack of awareness of how to safely and effectively initiate and titrate these medications. In this review article, we describe the different drug classes included in GDMT and offer an approach to initiation and effective titration in both the inpatient as well as outpatient setting.

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Author notes

  1. Jay Patel and Negin Rassekh contributed equally to this work.

Authors and Affiliations

  1. MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, 20010, USA

    Jay Patel, Negin Rassekh, Farooq H. Sheikh & Phillip H. Lam

  2. Georgetown University, Washington, DC, USA

    Jay Patel, Farooq H. Sheikh, Ali Ahmed & Phillip H. Lam

  3. University of California, Los Angeles, CA, USA

    Gregg C. Fonarow

  4. University of California, San Francisco, CA, USA

    Prakash Deedwania

  5. George Washington University, Washington, DC, USA

    Ali Ahmed

  6. Veterans Affairs Medical Center, Washington, DC, USA

    Ali Ahmed & Phillip H. Lam

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  1. Jay Patel
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Correspondence to Phillip H. Lam.

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Funding

Ali Ahmed was supported in part by research grants from the National Institutes of Health (1RF1AG069121, 1R01HL156518, and 1R01AG073474) and the Department of Veterans Affairs (I01HX002422 and 1I01HX003552).

Conflicts of interest

Gregg C. Fonarow reports consulting with Abbott, Amgen, Astra Zeneca, Bayer, Cytokinetics, Edwards, Eli Lilly, Janssen, Medtronic, Merck, Novartis, and Pfizer. Farooq H. Sheikh reports institutional research support from Abbott, Alnylam, and Ionis, and has received speaker’s fees from Abbott for an educational conference. Jay Patel, Negin Rassekh, Prakash Deedwania, Ali Ahmed, and Phillip H. Lam report no conflicts of interest in relation to this manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of their respective institutions.

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Patel, J., Rassekh, N., Fonarow, G.C. et al. Guideline-Directed Medical Therapy for the Treatment of Heart Failure with Reduced Ejection Fraction. Drugs 83, 747–759 (2023). https://doi.org/10.1007/s40265-023-01887-4

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