Table 20

Strategies for Achieving Optimal GDMT

  • 1. Uptitrate in small increments to the recommended target dose or the highest tolerated dose for those medications listed in Table 15 with an appreciation that some patients cannot tolerate the full recommended doses of all medications, particularly patients with low baseline heart rate or blood pressure or with a tendency to postural symptoms.

  • 2. Certain patients (e.g., the elderly, patients with chronic kidney disease) may require more frequent visits and laboratory monitoring during dose titration and more gradual dose changes. However, such vulnerable patients may accrue considerable benefits from GDMT. Inability to tolerate optimal doses of GDMT may change after disease-modifying interventions such as CRT.

  • 3. Monitor vital signs closely before and during uptitration, including postural changes in blood pressure or heart rate, particularly in patients with orthostatic symptoms, bradycardia, and/or “low” systolic blood pressure (e.g., 80 to 100 mm Hg).

  • 4. Alternate adjustments of different medication classes (especially ACE inhibitors/ARBs and beta blockers) listed in Table 15. Patients with elevated or normal blood pressure and heart rate may tolerate faster incremental increases in dosages.

  • 5. Monitor renal function and electrolytes for rising creatinine and hyperkalemia, recognizing that an initial rise in creatinine may be expected and does not necessarily require discontinuation of therapy; discuss tolerable levels of creatinine above baseline with a nephrologist if necessary.

  • 6. Patients may complain of symptoms of fatigue and weakness with dosage increases; in the absence of instability in vital signs, reassure them that these symptoms are often transient and usually resolve within a few days of these changes in therapy.

  • 7. Discourage sudden spontaneous discontinuation of GDMT medications by the patient and/or other clinicians without discussion with managing clinicians.

  • 8. Carefully review doses of other medications for HF symptom control (e.g., diuretics, nitrates) during uptitration.

  • 9. Consider temporary adjustments in dosages of GDMT during acute episodes of noncardiac illnesses (e.g., respiratory infections, risk of dehydration, etc).

  • 10. Educate patients, family members, and other clinicians about the expected benefits of achieving GDMT, including an understanding of the potential benefits of myocardial reverse remodeling, increased survival, and improved functional status and HRQOL.

ACE indicates angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; CRT, cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; HF, heart failure; and HRQOL, health-related quality of life.