Heart Failure with Reduced Ejection Fraction (HFrEF) Pearls with Dr. Michelle Kittleson

Understanding Heart Failure

• 💡 The most crucial first step when encountering heart failure is to determine its underlying cause, as this can significantly guide treatment decisions.
• 🧠 Potential causes to consider include family history, iron overload, thyroid disease, heavy alcohol use, or amyloidosis, especially in cases of new cardiomyopathy.
• 📊 BNP is useful for initial diagnosis and can be a poor prognosticator if elevated (>5,000) during hospitalization, but it should not be used for trending or guiding treatment decisions; clinical assessment is key.

Guideline-Directed Medical Therapy (GDMT) Pillars

• 🎯 The four main pillars of GDMT for HFrEF are: Angiotensin pathway inhibitors (ARNI/ACEI/ARB), beta-blockers (metoprolol succinate, carvedilol, bisoprolol), mineralocorticoid antagonists (spironolactone, eplerenone), and SGLT2 inhibitors (empagliflozin, dapagliflozin).
• 🚀 GDMT should be initiated rapidly, ideally during hospitalization, aiming to get patients to goal doses within approximately six weeks, as studies show significant risk reduction even in the short term.
• 📈 When initiating GDMT, it's recommended to start medications sequentially rather than all at once to identify and attribute any side effects to a specific drug.
• ⚡ The preferred order of initiation often starts with medications that improve symptoms quickly or have less impact on blood pressure, such as ARNI/ACEI/ARB, followed by MRA and SGLT2 inhibitors, while beta-blockers are best started once the patient is well-decongested.

Practical Treatment Considerations

• 💰 Cost can be a significant barrier, especially for ARNI and SGLT2 inhibitors. If a patient can only afford one expensive medication, prioritizing an ACE inhibitor and an SGLT2 inhibitor is suggested, as beta-blockers and MRAs are generally less expensive.
• 🔍 To understand why a patient might not be on all four pillars of GDMT, a