Moderators/Speakers: Dr Nancy Albert, Dr Muthu Vaduganathan, Dr Minal Kanti Das, Dr Bikam Bhaskur, Dr Robert Page

Clinical Realities and Priorities in Initiating GDMT for Heart Failure 

Key Highlights

Dr Nancy Albert and Dr Muthu Vaduganathan opened the session, outlining the goal of providing practical insights into initiating and optimising GDMT for heart failure patients. The panelists, including experts from India and the U.S., shared their clinical and research perspectives on overcoming real-world challenges in heart failure management.

Does Medication Sequence Matter in HFrEF?

Dr Bhaskur emphasised that achieving full GDMT quickly is more important than the sequence of drug initiation. Evidence suggests that initiating all four drug classes within weeks significantly reduces mortality and hospitalisation risks. In patients post-discharge, rapid up-titration should begin within two weeks.

Therapeutic Polypharmacy and Hospital-Based Initiation

Dr Robert Page encouraged clinicians to reframe polypharmacy as a therapeutic strategy, similar to combination treatments in oncology. Initiating GDMT during hospitalisation enables closer monitoring and increases medication adherence. Pharmacy teams play a crucial role in assessing renal function, blood pressure, potassium levels, and ensuring formulary availability of key drugs like Entresto and SGLT2 inhibitors.

Renal Function, Creatinine Rise, and SGLT2 Initiation

The panel discussed evolving renal function thresholds for GDMT initiation. SGLT2 inhibitors can be started at eGFR ≥20, while RAS inhibitors and MRAs are viable at eGFR ~30. Importantly, an initial creatinine rise after starting therapy is expected and should not be misinterpreted as kidney injury. Long-term use slows eGFR decline and reduces renal failure risk. Nephrology consultation is advised for patients with eGFR <20.

Managing the “Impossible Patient” and Hypotension

In cases of eGFR <20 or hyperkalaemia, the panel recommended carefully titrating therapy based on real-time renal function and potassium levels rather than avoiding GDMT altogether. Asymptomatic hypotension is not a contraindication, and therapy should not be discontinued solely based on low BP. The session concluded by reinforcing that the long-term mortality benefits of GDMT far outweigh initial BP or renal fluctuations.

Overcoming Barriers—Renal Dysfunction, Hyperkalaemia, Hypotension, and Cost in Heart Failure GDMT 

Key Highlights

Managing Hyperkalaemia and Renal Dysfunction in GDMT Initiation

Dr Das noted that potassium levels up to 5.4–5.5 mmol/L are acceptable for continuing RAS inhibitors, ARNI, and MRAs, particularly under nephrology supervision. He recommended potassium binders to manage levels proactively. Dr Albert suggested that hydralazine and nitrate combinations could serve as interim therapy in patients with severe renal dysfunction or hyperkalaemia, allowing later transition to core GDMT.

Optimising GDMT Sequencing in High-Risk Patients

For patients at risk of hyperkalaemia with borderline eGFR, Dr Bhaskur highlighted the benefit of starting SGLT2 inhibitors before MRAs, as this may enhance MRA tolerance. Concurrent use of diuretics was advised to manage volume status and potassium levels effectively.

Blood Pressure Considerations and Hypotension Management