What to Know About GDMT Heart Failure Medication
Medically reviewed by Richard N. Fogoros, MDMedically reviewed by Richard N. Fogoros, MDGuideline-directed medical therapy (GDMT) for heart failure describes evidence-based therapies that professional cardiology associations recommend for managing heart failure with reduced ejection fraction (HFrEF). Specifically, these guidelines come from the American College of Cardiology, American Heart Association, and Heart Failure Society of America.HFrEF is weakness of the heart muscle that leads to reduced contraction of the heart’s main pumping chamber, specifically an ejection fraction (EF) less than 40% (compared to normal EF of greater than 50%).
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Goal of GDMT for Heart FailureHeart failure is the weakness of the heart muscle that impairs blood flow to the body. It causes symptoms like shortness of breath, fatigue, and swelling that can interfere with daily activities. It also increases the risk of arrhythmias and sudden death. The goal of GDMT is to improve symptoms, prevent negative changes to the heart's structure and lower the risk of complications like hospitalization for heart failure and death.Healthcare providers commonly prescribe diuretics such as Lasix (furosemide) or Bumex (bumetanide) to manage fluid retention and swelling in heart failure as needed. Additional medications, known as the pillars of heart failure therapy, are backed by evidence for their ability to improve mortality and complications such as hospitalization for heart failure.Four Drug Types and GDMT OrderThe most recent recommendations from cardiology organizations have found found key medications for managing GDMT. It is recommended to start these medications within three months of a diagnosis of heart failure. These important medications include:Angiotensin receptor-neprilysin inhibitors (ARNI) such as Entresto (sacubitril/valsartan). This may be substituted with an angiotensin-converting enzyme (ACE) I inhibitor or angiotensin receptor blocker (ARB) if needed.Beta-blockers such as Zebeta (bisoprolol), Coreg (carvedilol), or Toprol XL (metoprolol succinate).Mineralocorticoid receptor antagonists such as Aldactone (spironolactone) or Inspra (eplerenone).Sodium-glucose cotransporter 2 (SGLT2) inhibitors such as Farxiga (dapagliflozin) or Jardiance (empagliflozin).
Adding Medications and Increasing DosageCardiologists may start with two or three of the medications at lower doses, and add the fourth and increase doses as tolerated. For example, someone with a new diagnosis of heart failure may start on a low dose of ARNI and beta-blocker, and within a few days or weeks, add a mineralocorticoid antagonist and SGLT2 inhibitor as their blood pressure allows. The goal is to take all four of the medications at the maximum tolerated doses that demonstrated benefit in the studies. A cardiologist or heart failure specialist can help manage the specific heart failure medications and doses.
Additional medications may be added based on individual characteristics. These may include:BiDil (Hydralazine and Isosorbide dinitrate) for Black people with heart failure who have symptoms despite treatment with the 4 pillars above. Studies showed improved survival and less hospitalization for heart failure on this medication.Procoralan (Ivabradine) for those with continued symptoms and heart rate of 70 or higher, despite taking tolerated doses of beta-blockers.Verquvo (Vericiguat) for selected patients with worsening heart failure.Medication Side Effects and InteractionsAll medications carry potential side effects and interactions with other medications. Additionally, depending on the cause and severity of heart failure, liver function, and kidney function, medications may be less well tolerated. Some medications are not recommended for use in pregnancy. Discuss all medications that you take, including over-the-counter medications and supplements, with your healthcare provider. Side effects of various heart failure medications are listed below.Beta-BlockersBeta-blockers counteract the effect of epinephrine (adrenaline). They can lower the heart rate and blood pressure and may cause the following symptoms:Erectile dysfunctionFatigueLight-headednessSleep problemsWorsening of asthmaARNIARNI is a combination of an angiotensin receptor blocker and neprilysin inhibitor. It can lower blood pressure and cause the following symptoms:Angioedema, a rare but serious reaction that causes swelling around the mouth and can impair breathing)Increased potassium levels in the blood (hyperkalemia)Volume depletionARNI should not be taken with ACE inhibitors or other ARBs, or with the direct renin inhibitor aliskiren.Mineralocorticoid Receptor AntagonistsMineralocorticoid antagonists are a type of diuretic and may cause the following:Breast tissue growthMenstrual changesVolume depletionHyperkalemiaSGLT2 InhibitorsSGLT2 Inhibitors work by blocking receptors in the kidney, and contribute to excretion of glucose (sugar) in the urine. SGLT2 inhibitors may cause:Volume depletionIncreased urinationDry mouthDecreased blood sugar, particularly if taking other glucose lowering medications such as sulfonylureasUrinary tract infectionsFungal infections of the genital areaNauseaFatigueAt-Home Management and Possible HospitalizationHeart failure is a chronic (long-term) disease that may have periods of worsening symptoms, known as heart failure exacerbation or flares. These are serious and may require treatment in a hospital. There, intravenous medications can be given to help manage excess volume and electrolyte abnormalities.At home, take your medications as prescribed and follow the recommendations of your healthcare team. They may ask you to limit the amount of salt in your diet and to limit your fluid intake. This is important to prevent fluid buildup, which leads to heart failure exacerbations.It's a good idea to keep track of the following and discuss any changes or concerns with your healthcare provider. It can help to keep a calendar or notebook to track the following:Symptom changesDaily weight, making note of any sudden weight gain that can indicate fluid buildup.Blood pressure and heart rate, being sure to discuss how to appropriately take your blood pressure at home, since there are many things that can lead to a falsely elevated blood pressure reading.Specialists Who Oversee GDMT TitrationCardiologists are heart specialists who diagnose and manage cardiovascular disease, including heart failure. Additionally, advanced heart failure practitioners are cardiologists who do extra training and focus on heart failure management. They also help manage people in need of heart pumps or a heart transplant.Some people may not have access to a cardiologist if they live far away from a medical center. In such cases, primary care clinicians play a big role in managing heart failure.
What Is Titration?Titration is the adjustment of medications and their dosages. For heart failure, this means increasing or decreasing doses of fluid pills (diuretics) and other medications, based on symptoms and how well the person is tolerating therapy. Sometimes doses need to be lowered if there are side effects.
While on GDMT: Ways to Support Heart HealthIn addition to taking medications to manage heart failure, a cardiologist may recommend the following to keep your heart healthy:Lower the amount of sodium (salt) in your diet. Note that salt is often in processed foods like canned soup and snack foods. Aim for less than 2 grams of salt per day.Eat a heart-healthy diet, with lots of fiber, vegetables, and fruits, and low in ultra-processed foods.Avoid alcohol.Quit smoking.Discuss exercise recommendations with your healthcare provider. It's generally beneficial to get moderate exercise if possible.SummaryGDMT for heart failure is a group of therapies to treat heart failure with reduced ejection fraction. These medications are supported by cardiology associations’ guidelines based on studies showing their benefit. They are used to treat heart failure and prevent complications like hospitalization and death.A cardiologist can tailor an individual approach that takes into account a person’s specific situation, and titrate the medication doses, and add additional recommended medications when indicated. Read the original article on Verywell Health.
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