Chapters Transcript Video Why & How to Titrate GDMT in HF So the topic of my talk today is why and how to titrate G. D. M. T. In heart failure. I have no relevant disclosures but like I'm one of the trial committee members for impulse dynamics. So heart failure as we know, is a highly prevalent with like extensive morbidity, mortality re hospitalizations and we have a lot of practice heart failure guidelines which give us which tell us how like to initiate GMT G. D. M. T guidelines. Medical directed therapy stands on four pillars. One is Arnie Arbs or ace inhibitors, second beta blockers, mres and two inhibitors in no particular order. But I'm going to talk about how to titrate subsequently. So why G. D. M. T. There is so much expansive data on why G. D. M. T. So I'm not gonna harp on that. I'm just gonna show you one pooled analysis here which actually is from emphasis paradigm and Dapa heart failure. So this pooled analysis shows how there is mortality benefit, there is hospitalization benefit and cv mortality and all cause mortality with G. D. M. T. And this comprehensive G. M. T. Four pillars while and then the comparison they've made to not know G. D. M. T. It's compared to a senna bitters are slash arts with beta blockers. So we see That's pretty significant hospitalization benefit mortality benefit and like this is the first graph a it's actually with age more than 55 years and you see the difference between comprehensive GMT and just to conventional therapeutic agents and the second graph is at 65 years of age. So the similar graphs or similar mortality benefit is seen like all cause mortality. This is just a retrospective observational study actually where they saw the mortality benefit with two inhibitors and our knees and this is not the four pillars. But you see the improvement with like the heart failure, mortality, heart failure, hospitalization and all cause mortality. So I think I've made my case and we also like recently this trial which was being done strong heart failure for initiation of G. D. M. T and acute heart failure in the hospitalization during the index hospitalization. So the results were so positive. So because this is prematurely terminated due to efficacy and the results were presented in H. A. Now how to titrate it. So I just have to allude briefly the stages of heart failure. One is stage A, which is just risk factors, where we just take care of risk factors and treat them accordingly. Stage B is actually evidence of structural heart disease, elevated mps or necrotic baptized or elevated filling pressures with a history of one hospitalization or fluid overload or any kind of like exacerbation but currently the patient is asymptomatic. So in this case this is stage be heart failure. Now I will focus on State C, which is a symptomatic heart failure which where most of the GMP is targeted but that does not mean that stage B can be ignored. Stage beef. The F is less than 40%. We should think about ace inhibitors and beta blockers offer me if this is less than 40%. Even after beta blockers should be initiated. These are class one. So this is the state c symptomatic heart failure. So once we have established the patient's heart failure while we're like working them up for the etiology, if it's not an ischemic we usually have to do extensive testing. We start all the four pillars together simultaneously in a clinic setting. Ah Then after that we have to monitor the patient clinically we do clinically we do lab markers, we do necrotic peptides and even the L. Like the echo parameters. So this is to initiate G. D. I like to like type of G. D. M. T. Now as we see in african american population there is for any class 3 to 4 heart failure. They recommend adding hydra lysine and survive on top of the basic four pillars. Now recommendations for beta blockers in patients. Hef ref three medications, carvedilol and XL long acting is actually absolutely indicated recommended and should be initiated. The M. R. E. S. Either spironolactone or a. It should be initiated if the G F. R. Is more than 30 and potassium is less than five as yet to do inhibitors should be recommended on all these patients for chronic therapy. They have shown significant mortality morbidity and hospitalization benefit. As I mentioned for patients african american patients. This is the risk reduction. You see the difference of G. D. M. T. Is just for reference like so basically we have to initiate G. D. M. T. To improve the mortality which is a very impressive mortality benefit particularly with better blockers and any simulators. Additional medical therapy. I'm just going to talk about of Aberdeen and allude to very sick because of Aberdeen is used in patients. It's 2 to 4 heart failure, patient predominantly sinus rhythm, you're not able to control the heart rate less than 70 despite being on maximum beta blockers or intolerant to beta blockers. Very sick. What is actually still struggling to find a role in active G. D. M. T. Because most of the times it only has a role probably in patients who are not able to tolerate Arnie for some reason and they have adequate blood pressure so it drops blood pressure because it works by the C. GMP pathway. So essentially this is all the mild reduced ejection fraction, 41 to 49%. Again there is no frank like recommendations but they mentioned that we have two ways SGL T. Two senators and like mres beta blockers, they all form like to consider it to be considerations. Now this is very important when I say heart failure with improved ejection fraction most patients will come to us and asked can we stop the G. D. M. T. Now that all these medications for medications and I feel fine. This is very important. There was a study done called treat heart failure and it's strongly recommended that we continue the lifelong therapy unless it's a very reversible cars, which is also questionable. We have to follow like harry potter cardiomyopathy, that's a separate topic in itself. So essentially we have to continue GMP despite improvement and ejection fraction preserved just to do is to a army is to be um sorry this is to be. But like the top cat subgroup analysis, I feel that there is a strong role because patients specifically in an american cohort. It has shown hospitalization benefit. Now the most important how to initiate G. D. M. T. So we strongly recommend in hospital initiation of G. D. M. T. These are the different trials that have shown the benefit. Now what it does is rapid improvement ejection fraction, rapid improvement in mortality benefit. There is improvement in therapy in hospitalizations, there is improvement in like compliance. All other safety net profile is established. So essentially when we start these like G. D. M. T. In the heart failure population in their index hospitalization we see more compliance, patients are more likely to fill their prescriptions medications and actually feel better and has shown that has multiple, multiple. It's very superior to doing it later because once we procrastinated to an outpatient setting and not initiated. The results are not as robust in hospital initiation. So you see the way we start is day 1-4. We initiate all the medications at a very, very low dose. The goal should be to uptight trade beta blocker like more rapidly rapidly the relative term here. So I will prefer out of all the four, I will start them and Arnie start them and load those beta blockers, try to titrate beta blockers and then keep the stable dose for army M. R. S. And we usually don't have too uptight trade by the end of like at least a week, the patient should be on robust doses, sorry, four weeks probation should be on robust doses of all the four triggers and as I mentioned, it has significant mortality morbidity and compliance, more compliance benefit, which is I think the biggest struggle with G. D. M. T, which we deal with in our clinical practice. Again, same thing harping on, we have established safety profile, we have established the efficacy profile, we established the cost benefit. Now cost benefit of two inhibitors is kind of like because we're still it's a newer medication, I think we will get there, so it's still mixed, but as long as we can we should try to initiate on all these four pillars. Uh so again, this is the simultaneous, this is like just a brief like I'm alluding to here, they're like beta blockers are needs and how how different they have mortality benefits, severe hospitalization benefit and how they are like improving the um morbidity profile. Now, maintenance. I think what we struggle here mostly is once patient gets admitted with hospitalization we tend to stop the Gmt and the goal here is please do not stop the G. D. M. T. S. If there is anything like which is such a pressing need that we have to like hold Gmt or half the dose before we discharge. We should reevaluate and see if we can put the patient back on Gmt or at least increase the dose. Also, again we mentioned in hospital index hospitalization we have to initiate G. D. M. T. Now the other two things we talk about most of the times people ask us as CKD and dialysis patients so I'm gonna just allude to CKD. So in the interest of time I'm going to move to this slide which just shows that how different G. D. M. T. S can be. Like we have to look at the G. F. R. Change in creatinine and how much we have better blockers need no change in emitters. Like if there's less than 50% increase in creating in less than 30% decrease in G fr, then we don't have to change anything. But after that we should have the does or stop medication and then we can take it from there and event reevaluate every 2 to 4 weeks. Similarly for analysis in the interest of time, I'll skip the slide but like we have enough data for beta blockers, we have a solicitors are needs, there is limited and conflicting observation analyses. So essentially my take home points are impatient infestation of g d m t. We have to rapidly escalate, choose, like follow up close follow up in GMT clinics and CKD Srd is not a contra indication, and we need to actually make sure that disparities, which is separate talking itself to address so that g d m t is accessible to all. Thank you. Published December 7, 2022 Created by Related Presenters Anju Bhardwaj, M.D. UT Health Houston View full profile
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