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Improving Heart Failure Care With GDMT
Expert Strategies for Improving Heart Failure Care With GDMT, Specialist Referral, and SGLT2 Inhibitors

Released: December 11, 2025

Ty J. Gluckman
Ty J. Gluckman, MD, MHA
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Key Takeaways
  • Healthcare professionals must overcome the risk–treatment paradox to ensure all patients with heart failure benefit from the rapid initiation of the 4 pillars of GDMT.
  • Worsening tolerance or down-titration of GDMT are examples of red flags that warrant referral to an advanced heart failure specialist.
  • Although cost continues to be a barrier for patients who need access to SGLT2 inhibitors, availability of generic formulations (eg, dapagliflozin) and/or cost reduction of some branded options in 2026 should help.

In this commentary, Ty J. Gluckman, MD, MHA, answers questions posed by healthcare professionals (HCPs) during a live symposium titled “Missed Opportunities in Heart Failure Care: Supporting Early Diagnosis With Cardiac Biomarkers and Maximizing Treatment Potential With SGLT2 Inhibitors.” Learn about specific considerations for implementing guideline-directed medical therapy (GDMT) for all patients with heart failure (HF), including the red flags that mark disease progression and warrant referral to a specialist as well as strategies to help address clinical inertia when prescribing SGLT2 inhibitors for HF.

What is the best approach to initiating and titrating GDMT, especially for more complex cases of HF?
It starts with recognizing that well-established therapies are underutilized in patients who have HF with reduced ejection fraction, HF with mildly reduced ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF).

In addition, there are some takeaways that I think bear calling out. The first is avoiding delayed treatment in HF, as the speed with which GDMT is initiated and optimized makes a difference. The STRONG-HF trial was key in proving this point. It showed that patient outcomes and symptoms were improved with rapid initiation of GDMT vs usual care in patients with HFrEF.

The second takeaway is that in-hospital initiation of GDMT is critical. Starting GDMT during a patient’s hospitalization increases the likelihood that they will continue their treatment post discharge—a key driver of long-term treatment adherence.

Third, there is a need to overcome the risk–treatment paradox in HF. Namely, patients at highest risk for adverse HF outcomes (ie, rehospitalization, death) tend to be the ones who are least likely to be prescribed GDMT. These patients include those of older age, with increased frailty, and with multiple comorbidities. Notwithstanding the challenges in addressing each of these issues, those at highest risk are often undertreated or slower to initiate therapy.

The fourth takeaway relates to the safety of GDMT. Although all medications have side effects, recommended therapies in HF have proven efficacy that largely outweighs potential risks.

The final takeaway asks HCPs to recognize the risks of omitting GDMT. We frequently discuss the risks associated with treatment initiation, but less often talk about the risks associated with omission of GDMT. Of importance, these include an increased risk of death and hospitalization.

What steps can you take to incorporate these in your practice? The first is rapid initiation of disease-modifying therapies, followed by expedited dose escalation to the doses that were studied in key clinical trials. One also needs to acknowledge that GDMT has cumulative impacts—the addition of different pillars of therapy has meaningful and incremental effects on survival and avoidance of hospitalization.

When should patients be referred to an HF specialist or advanced HF center?
This is challenging for both primary care HCPs and general cardiologists alike. I follow the acronym, “I NEED HELP”, which provides a list of clues or red flags suggesting that further assistance is likely needed.

  • I is for intravenous inotropes for support, most often in patients who are hospitalized
  • N is for New York Heart Association (NYHA) class (IIIB or IV) along with elevated natriuretic peptide levels
  • E is for end-organ dysfunction with worsening renal function, liver function, and/or other manifestations of progressive disease
  • E is also for ejection fraction, specifically a left ventricular ejection fraction <35%
  • D is for defibrillator shocks
  • H is for hospitalizations (>1)
  • E is for edema despite escalating diuretic therapy, with lack of response or resistance to standard doses
  • L is for low systolic blood pressure (<90 mm Hg); this is often accompanied by higher heart rates
  • P is for progressive intolerance or down-titration of GDMT

Although each of these scenarios alone stand as a reason to refer patients to an advanced HF specialist, “P” is one of the most important red flags. When patients start becoming intolerant of GDMT (stopping classes or decreasing the dose), it is a major sign that their HF is progressing.

What are the early signs of decompensation and how can HCPs intervene before hospitalization is needed?
When thinking about volume overload, it is important to realize that weight gain, lower extremity edema, and shortness of breath are usually late manifestations of worsening HF. I think it’s helpful to explain this to patients with a visual of a glass of water. If patients that are euvolemic (with or without HF) are a glass half full, then those with decompensated HF are a glass that is flowing over. Given this, how do you identify patients with worsening HF (a rising level of water in the glass) to intervene before weight gain, lower extremity edema, and shortness of breath occur?

Various tools can help with this. Implantable hemodynamic monitors, which most commonly sit in the pulmonary artery, allow for the detection of small increases in filling pressures in order to allow for adjustment of diuretic (and other medical) therapy. Wearable devices can help with this as well through assessment of thoracic bioimpedance—a measure of intrathoracic fluid levels. Finally, natriuretic peptide levels, which reflect levels of myocardial stress, represent another means to gauge worsening HF. Despite these tools, much more help is needed, as more than 1 million hospitalizations for HF are expected in the US this year.

Are there any red flags that would prompt urgent reassessment or a change in management strategy?
This question goes back to patients who should be referred to an advanced HF specialist based on the I NEED HELP acronym. Although several red flags exist, I especially worry about patients with repeated hospitalizations, low systolic blood pressure, and/or intolerance of or the need to down-titrate GDMT.

What tools or decision aids do you use to guide risk stratification and prognosis?
There are multiple risk-assessment tools that have been developed to help HCPs predict the risk for adverse outcomes in patients with HF. These can be used to predict a patients’ risk of hospitalization and mortality. One such tool is the Meta-Analysis of Global Group in Chronic Heart Failure (or MAGGIC) score, which is available online and incorporates multiple parameters, including a patients’ age, gender, systolic blood pressure, body mass index, serum creatinine, ejection fraction, and NYHA class. It also assesses smoking status, presence of diabetes or chronic obstructive pulmonary disease, timing of the HF diagnosis, and if treatments include a beta blocker, ACE inhibitor, ARB, or ARNI.

Risk calculators can vary, but they are intended to help HCPs predict disease trajectory and risks for a given patient. This is important, as patients previously hospitalized for HF face as high as a 75% 5-year mortality risk, regardless of left ventricular ejection fraction. This very much speaks to the poor prognosis of patients with HF and the need to do everything within one’s power to mitigate undesirable outcomes for these patients.

Of note, natriuretic peptide levels are not included in the MAGGIC score. Mixed data currently exist about the benefits of routinely measuring natriuretic peptide levels in patients with HF to guide treatment intensification and/or a change in therapy.

What is the most common patient-reported barrier or concern regarding SGLT2 inhibitors that you see in your practice and how do you address it?
Several potential barriers exist to use of SGLT2 inhibitors in HF, and HCPs must be prepared to address each one of them. SGLT2 inhibitors provide significant benefit in patients with HF, but they are not usually requested by patients. Rather, patients may ask “isn’t this a medication for diabetes?”. In this case, HCPs should acknowledge that although these therapies were developed to improve glycemic control in individuals with type 2 diabetes, they have proven benefit in patients with HF independent of whether a patient has diabetes or not.

Another question that may come up relates to the risks associated with use of SGLT2 inhibitors. It is important for HCPs to share with patients that multiple risks exist, including an increased risk of infection (ie, genital mycotic infection, urinary tract infection [UTI]). Although the prevalence of infection was low in clinical trials, patients should still be educated on good hygiene practices.

One of the biggest issues that I face in practice relates to polypharmacy in HF. Some patients will say, “I’m already on lots of medications (eg, a loop diuretic, beta blocker, and ACE inhibitor), isn’t that good enough?” Acknowledging this, it is important for HCPs to help patients understand the added clinical benefit afforded by an SGLT2 inhibitor, namely a reduced risk of cardiovascular mortality and hospitalization for HF.

Finally, cost considerations frequently come up. To this end, it’s important to know that the first generic SGLT2 inhibitor (dapagliflozin) is now available, although costs are only slightly lower. In 2026, costs of brand name dapagliflozin and empagliflozin are expected to decrease for Medicare beneficiaries.    

How can coordination between cardiology, endocrinology, nephrology, and primary care be optimized to ensure timely GDMT initiation and monitoring?
It is important for HCPs to understand that many patients with HF also have other cardiovascular, kidney, and metabolic abnormalities, also known as CKM syndrome. Fortuitously, many of the therapies (ie, ACE inhibitors, ARBs, ARNIs, MRAs, SGLT2 inhibitors, and GLP-1 receptor agonists) that are increasingly used in HF have additional benefits when treating these other conditions. That is why nephrologists, endocrinologists, primary care providers, and cardiologists should find ways to coordinate care in order to ensure timely initiation of these therapies.

Yet, current data suggest that such therapies are significantly underutilized across these conditions. Is this a problem of too many “cooks in the kitchen” or a question of which HCP wants to take primary responsibility for initiating these therapies? Regardless, challenges in communication persist, and they may be accentuated by not being on the same electronic health record (EHR). Personally, I think underuse of these therapies reflects a much larger, systems-based problem, with the need to find ways to simplify the initiation and titration (where appropriate) of these important medications.

Lack of care coordination can also be made more difficult by the fact that these medications have effects well beyond improving HF outcomes. For example, initiation of an SGLT2 inhibitor in a patient with HF and type 2 diabetes may require dose adjustment or cessation of other medications used to improve glycemic control (eg, insulin, oral sulfonylurea). To avoid hypoglycemia, optimal care entails a conversation between a patient’s cardiologist and their endocrinologist or primary care provider. Another approach is the utilization of clinical pharmacists to help oversee/coordinate medical management of many of the most common forms of chronic disease.

How long should patients wait for a UTI to resolve before restarting their SGLT2 inhibitor?
If you’re seeing a patient with HF for the first time and they happen to have a genital mycotic infection or UTI, it’s not the best time to start an SGLT2 inhibitor. Ideally, you should wait until they have completed their course of antibiotic or antifungal therapy and symptoms have resolved.

For patients already on an SGLT2 inhibitor that develop an uncomplicated UTI or genital mycotic infection, the SGLT2 inhibitor does not usually have to be stopped. On the flip side, patients with complex or recurrent UTIs/genital mycotic infections despite good hygiene should stop their SGLT2 inhibitor. Thereafter, care should be coordinated with their primary care provider and/or urologist to determine if an SGLT2 inhibitor can be safely reinitiated.

Your Thoughts
How often do you prescribe the 4 pillars of GDMT or note to the patient’s prescribing HCP that additional GDMT therapies are needed in your patients with HF? You can get involved in the discussion by answering the poll question and posting a comment below.

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How often do you prescribe the 4 pillars of GDMT or note to the patient’s prescribing HCP that additional GDMT therapies are needed in your patients with HF?

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