Treating Cardiac Edema

What To Know About GDMT Heart Failure Medication

Guideline-directed medical therapy (GDMT) for heart failure describes evidence-based therapies that professional cardiology associations recommend for managing heart failure with reduced ejection fraction (HFrEF). Specifically, these guidelines come from the American College of Cardiology, American Heart Association, and Heart Failure Society of America.

HFrEF is weakness of the heart muscle that leads to reduced contraction of the heart's main pumping chamber, specifically an ejection fraction (EF) less than 40% (compared to normal EF of greater than 50%).

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Goal of GDMT for Heart Failure Heart failure is the weakness of the heart muscle that impairs blood flow to the body. It causes symptoms like shortness of breath, fatigue, and swelling that can interfere with daily activities. It also increases the risk of arrhythmias and sudden death. The goal of GDMT is to improve symptoms, prevent negative changes to the heart's structure and lower the risk of complications like hospitalization for heart failure and death. Healthcare providers commonly prescribe diuretics such as Lasix (furosemide) or Bumex (bumetanide) to manage fluid retention and swelling in heart failure as needed. Additional medications, known as the pillars of heart failure therapy, are backed by evidence for their ability to improve mortality and complications such as hospitalization for heart failure. Four Drug Types and GDMT Order The most recent recommendations from cardiology organizations have found found key medications for managing GDMT. It is recommended to start these medications within three months of a diagnosis of heart failure. These important medications include: Angiotensin receptor-neprilysin inhibitors (ARNI) such as Entresto (sacubitril/valsartan). This may be substituted with an angiotensin-converting enzyme (ACE) I inhibitor or angiotensin receptor blocker (ARB) if needed. Beta-blockers such as Zebeta (bisoprolol), Coreg (carvedilol), or Toprol XL (metoprolol succinate). Mineralocorticoid receptor antagonists such as Aldactone (spironolactone) or Inspra (eplerenone). Sodium-glucose cotransporter 2 (SGLT2) inhibitors such as Farxiga (dapagliflozin) or Jardiance (empagliflozin). Adding Medications and Increasing Dosage Cardiologists may start with two or three of the medications at lower doses, and add the fourth and increase doses as tolerated. For example, someone with a new diagnosis of heart failure may start on a low dose of ARNI and beta-blocker, and within a few days or weeks, add a mineralocorticoid antagonist and SGLT2 inhibitor as their blood pressure allows. The goal is to take all four of the medications at the maximum tolerated doses that demonstrated benefit in the studies. A cardiologist or heart failure specialist can help manage the specific heart failure medications and doses.

Additional medications may be added based on individual characteristics. These may include:

BiDil (Hydralazine and Isosorbide dinitrate) for Black people with heart failure who have symptoms despite treatment with the 4 pillars above. Studies showed improved survival and less hospitalization for heart failure on this medication.

Procoralan (Ivabradine) for those with continued symptoms and heart rate of 70 or higher, despite taking tolerated doses of beta-blockers.

Verquvo (Vericiguat) for selected patients with worsening heart failure.

Medication Side Effects and Interactions All medications carry potential side effects and interactions with other medications. Additionally, depending on the cause and severity of heart failure, liver function, and kidney function, medications may be less well tolerated. Some medications are not recommended for use in pregnancy. Discuss all medications that you take, including over-the-counter medications and supplements, with your healthcare provider. Side effects of various heart failure medications are listed below. Beta-Blockers Beta-blockers counteract the effect of epinephrine (adrenaline). They can lower the heart rate and blood pressure and may cause the following symptoms: Erectile dysfunction Fatigue Light-headedness Sleep problems Worsening of asthma ARNI ARNI is a combination of an angiotensin receptor blocker and neprilysin inhibitor. It can lower blood pressure and cause the following symptoms: Angioedema, a rare but serious reaction that causes swelling around the mouth and can impair breathing) Increased potassium levels in the blood (hyperkalemia) Volume depletion ARNI should not be taken with ACE inhibitors or other ARBs, or with the direct renin inhibitor aliskiren. Mineralocorticoid Receptor Antagonists Mineralocorticoid antagonists are a type of diuretic and may cause the following: Breast tissue growth Menstrual changes Volume depletion Hyperkalemia SGLT2 Inhibitors SGLT2 Inhibitors work by blocking receptors in the kidney, and contribute to excretion of glucose (sugar) in the urine. SGLT2 inhibitors may cause: Volume depletion Increased urination Dry mouth Decreased blood sugar, particularly if taking other glucose lowering medications such as sulfonylureas Urinary tract infections Fungal infections of the genital area Nausea Fatigue At-Home Management and Possible Hospitalization Heart failure is a chronic (long-term) disease that may have periods of worsening symptoms, known as heart failure exacerbation or flares. These are serious and may require treatment in a hospital. There, intravenous medications can be given to help manage excess volume and electrolyte abnormalities. At home, take your medications as prescribed and follow the recommendations of your healthcare team. They may ask you to limit the amount of salt in your diet and to limit your fluid intake. This is important to prevent fluid buildup, which leads to heart failure exacerbations. It's a good idea to keep track of the following and discuss any changes or concerns with your healthcare provider. It can help to keep a calendar or notebook to track the following: Symptom changes Daily weight, making note of any sudden weight gain that can indicate fluid buildup. Blood pressure and heart rate, being sure to discuss how to appropriately take your blood pressure at home, since there are many things that can lead to a falsely elevated blood pressure reading. Specialists Who Oversee GDMT Titration Cardiologists are heart specialists who diagnose and manage cardiovascular disease, including heart failure. Additionally, advanced heart failure practitioners are cardiologists who do extra training and focus on heart failure management. They also help manage people in need of heart pumps or a heart transplant. Some people may not have access to a cardiologist if they live far away from a medical center. In such cases, primary care clinicians play a big role in managing heart failure. What Is Titration? Titration is the adjustment of medications and their dosages. For heart failure, this means increasing or decreasing doses of fluid pills (diuretics) and other medications, based on symptoms and how well the person is tolerating therapy. Sometimes doses need to be lowered if there are side effects. While on GDMT: Ways to Support Heart Health In addition to taking medications to manage heart failure, a cardiologist may recommend the following to keep your heart healthy: Lower the amount of sodium (salt) in your diet. Note that salt is often in processed foods like canned soup and snack foods. Aim for less than 2 grams of salt per day. Eat a heart-healthy diet, with lots of fiber, vegetables, and fruits, and low in ultra-processed foods. Avoid alcohol. Quit smoking. Discuss exercise recommendations with your healthcare provider. It's generally beneficial to get moderate exercise if possible. Summary GDMT for heart failure is a group of therapies to treat heart failure with reduced ejection fraction. These medications are supported by cardiology associations' guidelines based on studies showing their benefit. They are used to treat heart failure and prevent complications like hospitalization and death. A cardiologist can tailor an individual approach that takes into account a person's specific situation, and titrate the medication doses, and add additional recommended medications when indicated.    10 Sources Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. American Heart Association. Heart failure signs and symptoms. Maddox TM, Januzzi JL Jr, Allen LA, et al. 2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2024;83(15):1444-1488. Doi:10.1016/j.Jacc.2023.12.024 MedlinePlus. Drug Reactions. Riemer TG, Villagomez Fuentes LE, Algharably EAE, et al. Do β-Blockers Cause Depression?: Systematic Review and Meta-Analysis of Psychiatric Adverse Events During β-Blocker Therapy. Hypertension. 2021;77(5):1539-1548. Doi:10.1161/HYPERTENSIONAHA.120.16590 Kallistratos MS, Pittaras A, Theodoulidis I, Grassos C, Poulimenos LE, Manolis AJ. Adverse Effects of Mineralocorticoid Receptor Antagonist Administration. Curr Pharm Des. 2018;24(46):5537-5541. Doi:10.2174/1381612825666190222144359 Pittampalli S, Upadyayula S, Mekala HM, Lippmann S. Risks vs Benefits for SGLT2 Inhibitor Medications. Fed Pract. 2018 Jul;35(7):45-48. Chrysohoou C, Mantzouranis E, Dimitroglou Y, Mavroudis A, Tsioufis K. Fluid and Salt Balance and the Role of Nutrition in Heart Failure. Nutrients. 2022 Mar 26;14(7):1386. Doi:10.3390/nu14071386 American Heart Association. Managing Heart Failure Symptoms. American College of Cardiology. No Practicing Cardiologist in Nearly Half of US Counties, Despite Higher CV, Mortality Risk. American Heart Association. Life's Essential 8. By Angela Ryan Lee, MDDr. Lee is an Ohio-based board-certified physician specializing in cardiovascular diseases and internal medicine. Was this page helpful? Thanks for your feedback! What is your feedback? Other Helpful Report an Error

Semaglutide Lowers Heart Failure Risks In Patients With Type 2 Diabetes, CKD

Semaglutide reduces risks heart failure (HF) and cardiovascular death in a high-risk population with both type 2 diabetes and chronic kidney disease (CKD), according to the latest data from the FLOW trial. The findings were presented at the European Society of Cardiology (ESC) Congress in London, UK, and concurrently reported in the Journal of the American Society of Cardiology.1

In the phase 3 FLOW trial (NCT03819153), 3533 patients with both type 2 diabetes and CKD were randomly assigned to receive 1 mg weekly of subcutaneous semaglutide, a glucagon-like peptide-1 receptor agonist or placebo and followed for a median of 3.4 years. At baseline, patients had an estimated glomerular filtration rate (eGFR; in mL/min/1.73m2) of 50 to 75 and a urine albumin-to-creatinine ratio (UACR) of 300 to less than 5000 mg/g or an eGFR of 25 to less than 50 and a UACR of 100-5000 mg/g. Patients were taking a stable maximum tolerated dose of an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker and could also be treated with an SGLT2 inhibitor or mineralocorticoid receptor antagonist.

Previously published results showed semaglutide reduced the risk for major kidney outcomes, the trial's primary endpoint.

This prespecified analysis centered on HF outcomes. Overall, semaglutide significantly reduced the composite risk of first HF events or cardiovascular death by 27% compared with placebo, Richard E. Pratley, MD, of AdventHealth Translational Research Institute in Orlando, Florida, and colleagues reported. The GLP1-RA significantly reduced the risk of HF events alone by 27%, defined as new onset or worsening HF leading to hospital admission or an urgent visit requiring initiation or intensification of diuretic/vasoactive therapy. Semaglutide reduced the risk of cardiovascular death alone by 29%.

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The FLOW trial provides important additional evidence supporting CV benefits of GLP-1 Ras in high-risk populations, yet its findings on HF outcomes should be interpreted with caution.

Semaglutide significantly reduced the composite HF outcome even in the subset of patients with an eGFR less than 30 mL/min/1.73 m2.

At baseline, HF affected 19.4% of the semaglutide group and 19.0% of the placebo group. Among those with HF history, 47.9% had preserved ejection fraction (HFpEF), 18.1% had reduced ejection fraction (HFrEF), and 33.9% were unclassified.

Both patients with and without a history of HF experienced a reduction in the composite heart failure outcome, Dr Pratley's team reported. Patients with NYHA functional class III or with HFrEF, however, generally had higher risks for the composite outcome, regardless of treatment. Baseline body mass index for patients with and without HF was 33.3 and 30.8 kg/m2, respectively.

"The effects of semaglutide were also comparable across a variety of clinically relevant subgroups, including those defined by KDIGO risk class, prior ASCVD events, and background medications, including SGLT2 inhibitors and MRAs," Dr Pratley's team wrote.

In an accompanying editorial, Veraprapas Kittipibul, MD, and Robert J. Mentz, MD, of Duke University Medical Center in Durham, North Carolina, pointed out that HF events were assessed by investigators rather than strict criteria.2

"The FLOW trial provides important additional evidence supporting CV benefits of GLP-1 Ras in high-risk populations, yet its findings on HF outcomes should be interpreted with caution," they wrote. "The reliance on investigator-determined baseline HF diagnosis without standardized criteria, coupled with the absence of supporting evidence such as natriuretic peptide levels or history of HF hospitalizations, results in some uncertainty about the representativeness of the HF cohort in this analysis compared with the broader HF population."

Adverse events leading to treatment discontinuation were more common in the semaglutide than placebo group in those with baseline HF (12.9% vs 10.4%) and those without (13.3% vs 12.3%), driven mainly by gastrointestinal disorders.

This trial update shows that "regardless of your kidney function, if you have type 2 diabetes and chronic kidney disease, this is very likely a drug that we should be adding to other guideline-directed medical therapies," ESC vice president Carlos Aguiar, MD, said in an interview with JAMA.3

Disclosure: This research was supported by Novo Nordisk. Please see the original reference for a full list of disclosures.

This article originally appeared on Renal and Urology News

14 Strategies To Prevent Heart Disease

You can take steps to prevent heart disease. About 47% of Americans have at least one controllable risk factor for heart disease, such as high blood pressure (hypertension), high cholesterol, diabetes, smoking, obesity, and low activity levels. Risk factors for heart disease that are out of your control include family history, ethnicity, sex, and age.

Heart disease is the leading cause of death for people of any sex and all racial and ethnic groups. Untreated heart disease can lead to heart attack, stroke, heart failure, and death. While it tends to be more common in older adults, heart disease can affect anyone at any age. The average age for people who die of coronary heart disease or a heart attack is 65 or older.

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1. Avoid Smoking, Vaping, or Using Tobacco A smoker's risk for coronary heart disease is 2 to 4 times that of a nonsmoker's risk. People who smoke at least one pack of cigarettes a day have twice the risk of heart attack compared to those who have never smoked. Vaping might be less harmful than smoking, but it is still not safe for your heart and lungs. Nicotine is used in both regular cigarettes and vaping products and is highly addictive. Nicotine is a toxic substance that raises blood pressure and heart rate, which increases the possibility of a heart attack. Quitting smoking, vaping, and tobacco products isn't easy. Talk to a healthcare provider about quitting. Treatments and resources are available.  2. Limit Alcohol Alcohol can raise your heart disease risk in various ways. This includes: Raising Blood Pressure Alcohol can cause your blood pressure to go up temporarily, and the more you drink, the higher it will increase. If you have a history of high blood pressure, you might consider avoiding alcohol entirely or only drinking occasionally. Increasing Heart Rate Drinking alcohol can cause your heart rate to increase in speed, and if it goes over 100 beats per minute, you may experience tachycardia. If you have frequent episodes of tachycardia, your risk for heart failure, heart attack, or stroke is higher.  Causing an Irregular Heart Rhythm If you overdo or overindulge in alcohol, you could have a condition called atrial fibrillation (A-fib), which is an irregular heart rhythm. A-fib can increase your risk for heart failure, heart attack, and stroke.  Promoting Alcoholic Cardiomyopathy Alcoholic cardiomyopathy is a consequence of long-term alcohol use. It causes the heart's pumping function to get weak and the heart to become enlarged.  If you are an occasional drinker, it may not increase your heart disease risk, provided you do not have other heart disease risk factors. But you will need to avoid consistently overindulging in alcohol.  3. Get Regular, Daily Exercise Exercise is an excellent way to prevent heart disease. It can also help you to manage your weight.  The American Heart Association recommends at least 150 minutes of heart-pumping physical activity per week. It also recommends spending less time sitting. If you are unable to participate in more intense exercises, engage in light activity to keep moving.  4. Follow a Heart-Healthy Diet A heart-healthy diet promotes eating minimally processed foods, including fruits and vegetables, whole grains, and beans. It also involves avoiding ultra-processed foods, sugars, and unhealthy fats.  Examples of heart-healthy foods are: Fruits: Most fruits are cardioprotective because they are high in fiber, vitamins, and minerals, as well as antioxidant and anti-inflammatory compounds like anthocyanins.  Vegetables: Some types of vegetables, including cruciferous vegetables and leafy greens, are heart-healthy.  Seafood: Seafood is high in omega-3 fatty acids, which benefit your heart health. Research shows that eating fish can reduce the risk of heart disease and heart disease-related death. Legumes: Beans and lentils are loaded with fiber and essential minerals like magnesium and potassium, which means they are good for your heart. Studies show that diets high in legumes are associated with a lower risk for obesity, diabetes, high blood pressure, and heart disease. Whole grains: Quinoa, brown rice, and oats are whole grains that are high in fiber and other nutrients linked to improved heart health. Replacing refined grains like white rice, white bread, and pasta with whole grains may help reduce your risk of heart disease. Healthy fats: Adding healthy fats like olive oil, nuts, seeds, avocado, and fatty fish (i.E., salmon and mackerel) may help improve your heart health. Olive oil, which is a part of the Mediterranean diet, is especially cardioprotective.  Spices: Spices like turmeric, ginger, and saffron have powerful anti-inflammatory properties and may reduce your risk for heart disease. 5. Manage Your Weight Being overweight, especially in the middle part of the body, can increase your risk for heart disease and conditions that add to your heart disease risk (high blood pressure, high cholesterol, and type 2 diabetes). Even a small amount of weight loss can be helpful. Reducing your weight by 3% to 5% can help lower fats found in the blood called triglycerides. It can also reduce your risk of type 2 diabetes and lower your blood pressure and cholesterol levels.  Obesity is considered a medical disease, and many in the medical community have changed their practices for managing it. That means your healthcare provider has many tools at their disposal to help you lose weight and keep it off.  6. Get Quality Sleep Getting enough good quality sleep is vital to your heart and brain health. People who do not sleep well have a higher risk for high blood pressure, diabetes, depression, and obesity.  You need at least seven hours of sleep every night. Set a sleep schedule and stick to it. Practice good sleep hygiene, which includes both daytime habits and bedtime routines to make it easier for you to fall asleep at night and stay asleep until morning.  Talk to your healthcare provider if you wake up not feeling rested or if you struggle with daytime fatigue. They will evaluate you to determine the cause of your sleep troubles. 7. Manage Stress It is unknown how stress contributes to heart disease, but negative mental health is linked to heart disease and stroke. On the other hand, positive mental health is associated with a lower risk for both conditions.  Keep your stress levels down with exercise, meditation, yoga, hobbies, or listening to music. Even simple breathing exercises can help you better respond to stress.  If stress becomes too much, let a healthcare provider know. Ongoing stress can lead to anxiety and depression, so it is important to get treatment.  8. Avoid Infections Researchers have linked certain infections like pneumonia and gum infections to coronary events, such as heart attack or stroke. If you already have heart problems, getting an infection can make it worse.  To reduce your risk for infections that may affect your heart health, take precautions. For example: Brush and floss daily: Gum disease is a risk factor for heart disease, so you should do what you can to reduce your risk. Make sure you also get regular dental checkups. Get vaccinated: Get your yearly flu shot. You should also be vaccinated against COVID-19 and pneumonia. Check with your healthcare provider if you need any other vaccines.  Reduce your risk for infections: Taking simple precautions can help you to avoid getting sick. Washing your hands, not sharing personal items, practicing food safety, wearing a face mask, practicing safe sex, and traveling safely are all ways to help you avoid infectious diseases. 9. Lower Your Blood Pressure High blood pressure is known as a silent killer because it does not always cause symptoms. Left untreated, it may damage the blood vessels. Hypertension has no cure. It can lead to heart disease, heart attack, and stroke. Fortunately, there are things you can do to keep your blood pressure at healthy levels. Check with your healthcare provider where your blood pressure should be based on your age and medical history. In general, you will want to aim for a blood pressure that is at or below 120/80 millimeters of mercury (mm Hg). To manage your blood pressure: Maintain a healthy weight. Eat a low-sodium diet. Limit your alcohol intake. Do not smoke.  Take blood pressure medication if prescribed by your medical provider. 10. Lower Your Bad Cholesterol (LDL) There are two main types of cholesterol: low-density lipoprotein (LDL) cholesterol ("bad cholesterol") and high-density lipoprotein (HDL) cholesterol ("good cholesterol"). LDL can lead to artery-clogging plaque, while HDL works to clear bad cholesterol from the blood.  Studies have consistently found that lowering your LDL cholesterol can reduce your risk for heart disease, heart attacks, and stroke. It may also reduce the need for cardiac catheterization or bypass surgery. Lifestyle modifications, such as a heart-healthy diet, quitting smoking, regular exercise, and weight loss, can lower LDL cholesterol. If your healthcare provider prescribes cholesterol-lowering medications, make sure you are taking them as prescribed.  11. Raise Your Good Cholesterol HDL cholesterol is known as good cholesterol because it works to pick up excess cholesterol in the blood. It then takes it to the liver, where it is broken down and removed from the body.  You can boost your HDL levels by: Consuming foods high in omega-3 fatty acids, such as fatty fish, flaxseed, beans, and walnuts Taking fish oil supplements  Following a Mediterranean diet  Avoiding trans fats, such as found in frozen pizza, margarine and spreads, and baked goods Reducing sugar intake Engaging in physical activity Not smoking 12. Manage Diabetes People with diabetes have an increased risk for heart disease. This is because diabetes increases your risk for other heart disease risk factors—high blood pressure, high cholesterol, and high triglycerides. High blood sugar also damages blood vessels. Talk to your healthcare provider about ideal blood sugar and hemoglobin A1c numbers. They may suggest exercise, medications, and a diabetes nutrition plan to help you meet your goals.  13. Take Any Medications as Prescribed If your medical provider prescribes medications to treat diabetes, high blood pressure, high cholesterol, or another risk factor condition, make sure you take them. You will also need to follow any guidance they provide on how to take the medications.   14. Have Regular Health Screening Tests Keeping up with appointments allows your healthcare provider to catch signs of heart disease early. Regular screenings for blood pressure, cholesterol, and type 2 diabetes can tell them whether you need to take any action.  As with any health condition, early diagnosis increases your chances for success and reduces your risk for complications.  Your provider can monitor your heart health with some simple tests. These include: A weight and body mass index (BMI) assessment  Blood pressure measurements Blood tests for cholesterol and blood sugar  Asking questions about your diet, activity levels, and smoking history  Asking about personal and family medical history  Asking about health changes or current symptoms  If your provider suspects a heart condition, they will request additional testing that checks the heart. Tests that check the heart include: Discuss your heart disease risk factors with your healthcare provider. They can help you develop a plan to improve your health outcomes.  Summary  Risk factors for heart disease include things like smoking and an unhealthy diet, which are preventable. They also include risk factors like age, sex, and family history, which are out of your control. Making lifestyle changes can reduce your risk for heart disease. These changes include eating a heart-healthy diet, being active, maintaining a healthy weight, quitting smoking, and managing blood pressure, cholesterol levels, and diabetes.  Discuss your individual risk factors with a healthcare provider. They can advise you on the best ways to reduce your risk of heart disease.

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