170 An evidence-based approach to overcoming barriers in initiating and up-titrating guideline- directed medical therapy in patients with heart failure with reduced ejection fraction

Introduction Guideline-directed medical therapy (GDMT) has unequivocal mortality benefits in patients with heart failure with reduced ejection fraction (HFrEF). However, real world studies show that their uptake is often limited due to concerns of adverse effects. Objective To synthesise an evidence-based approach to implement and up-titrate GDMT in HFrEF patients with hypotension, hyperkalaemia and poor renal function. Methods We reviewed major HF guidelines (2021 ESC Guideline, 2023 Focused Update of 2021 ESC Guideline & 2022 AHA/ACC/ HFSA Guideline) for practical guidance on use of GDMT. We also studied the inclusion and exclusion criteria, and adverse effect profiles of foundational drugs angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), angiotensin receptor/neprilysin inhibitor (ARNI), beta-blocker (BB), mineralocorticoid receptor antagonist (MRA) and sodium-glucose co-transporter 2 inhibitor (SGLT2I) in contemporary landmark trials. Pharmacological properties of the individual drugs were also considered. Results Patients with asymptomatic hypotension [systolic blood pressure (SBP) 5.5 mmol/L, initiation of potassium binders (e.g., sodium zirconium cyclosilicate & patiromer) is warranted. In these patients, BB and SGLT2I can be initiated in the first step. SGLT2I, with its diuretic effect, may help to reduce potassium level further. ARNI can be initiated next, provided potassium is controlled (Conclusion Hypotension, hyperkalaemia and poor renal function are significant clinical barriers that contribute to underutilisation of GDMT. Adopting evidence-based strategies using an individualised approach to initiate and up-titrate medications may help overcome therapeutic inertia and optimise the management of patients with HFrEF. Conflict of Interest None