Author + information
- Received January 17, 2018
- Revision received April 28, 2018
- Accepted April 30, 2018
- Published online December 31, 2018.
- Aditi A. Bhagat, MD, MPHa,∗,
- Stephen J. Greene, MDb,c,∗,
- Muthiah Vaduganathan, MD, MPHd,
- Gregg C. Fonarow, MDe and
- Javed Butler, MD, MPH, MBAf,∗ (, )@JavedButler1
- aDivision of Cardiology, Stony Brook University, Stony Brook, New York
- bDuke Clinical Research Institute, Durham, North Carolina
- cDivision of Cardiology, Duke University School of Medicine, Durham, North Carolina
- dBrigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
- eAhmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, California
- fDepartment of Medicine, University of Mississippi, Jackson, Mississippi
- ↵∗Address for correspondence:
Dr. Javed Butler, Department of Medicine, University of Mississippi, L650, 2500 North State Street, Jackson, Mississippi 39216.
Patients with worsening heart failure with reduced ejection fraction (HFrEF) spend a large proportion of time in the hospital and other health care facilities. The benefits of guideline-directed medical therapy (GDMT) in the outpatient setting have been shown in large randomized controlled trials. However, the decision to initiate, continue, switch, or withdraw HFrEF medications in the inpatient setting is often based on multiple factors and subject to significant variability across providers. Based on available data, in well-selected, treatment-naïve patients who are hemodynamically stable and clinically euvolemic after stabilization during hospitalization for HF, elements of GDMT can be safely initiated. Inpatient continuation of GDMT for HFrEF appears safe and well-tolerated in most hemodynamically stable patients. Hospitalization is also a potential time for switching from an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker to sacubitril/valsartan therapy in eligible patients, and is the subject of ongoing study. Therapy withdrawal or need for dose reduction is rarely required, but if needed identifies a particularly at-risk group of patients with progressive HF. If recurrent intolerance to neurohormonal blockers is observed, these patients should be evaluated for advanced HF therapies. There is an enduring need for using the teachable moment of HFrEF hospitalization for optimal initiation, continuation, and switching of GDMT to improve post-discharge patient outcomes and the quality of chronic HFrEF care.
↵∗ Drs. Bhagat and Greene contributed equally to this work and are joint first authors of this paper.
Dr. Greene has received the NHLBI T32 postdoctoral training grant (T32HL069749-14), a Heart Failure Society of America/Emergency Medicine Foundation Acute Heart Failure Young Investigator Award funded by Novartis; and research support from Novartis and Amgen. Dr. Vaduganathan has received the NHLBI T32 postdoctoral training grant (T32HL007604). Dr. Fonarow has received personal fees from Novartis, Amgen, Janssen, Medtronic, and St. Jude Medical. Dr. Butler is a principal investigator of the EMPEROR program (Boehringer Ingelheim); has received research support from the NIH and the European Union; and has received personal fees from Amgen, Array, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Janssen, Novartis, Relypsa, ZS Pharma, Medtronic, Merck, CVRx, G3 Pharmaceuticals, Lutipold, Stealth Peptide, SC Pharma, and Vifor. Dr. Bhagat has reported that he has no relationships relevant to the contents of this paper to disclose.
- Received January 17, 2018.
- Revision received April 28, 2018.
- Accepted April 30, 2018.
- 2019 American College of Cardiology Foundation
This article requires a subscription or purchase to view the full text. If you are a subscriber or member, click Login or the Subscribe link (top menu above) to access this article.