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GDMT Titration Priority — EECC MCQ

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ModerateHeart FailureGDMT Titration PriorityEECC

A 58-year-old man with newly diagnosed HFrEF (LVEF 28%) is started on quadruple GDMT. Which medication should be uptitrated to target dose most urgently given its early mortality benefit?

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Correct answer: B — Beta-blocker (bisoprolol or carvedilol) — up-titrate every 2-4 weeks

While all four pillars of GDMT (ACEi/ARNI, beta-blocker, MRA, SGLT2i) should be initiated early, beta-blockers should be up-titrated to the maximum tolerated dose relatively urgently, as the mortality benefit is dose-dependent (CIBIS-II, MERIT-HF, COPERNICUS). The STRONG-HF trial demonstrated that rapid up-titration of GDMT (especially beta-blocker and RAAS inhibitors) with close follow-up within 2 weeks improves outcomes compared to slow titration. SGLT2 inhibitors are given at fixed dose (dapagliflozin 10 mg or empagliflozin 10 mg) and do not require titration. MRA doses are typically low-dose (spironolactone 25-50 mg). The key is simultaneous initiation with rapid sequential up-titration.

Reference: ESC (2023): Focused Update on Heart Failure; STRONG-HF Trial