Simultaneous GDMT Initiation — EECC MCQ

Correct answer: B — All four pillars (ACEi/ARNI + beta-blocker + MRA + SGLT2i) should ideally be initiated simultaneously or in rapid sequence within the first 4 weeks, rather than sequentially uptitrating one agent at a time before starting the next

The traditional stepwise approach (start one agent, titrate to target, then add the next) delays achievement of full GDMT by months, during which patients remain undertreated and at risk. The 2023 ESC HF Focused Update, informed by the STRONG-HF trial, recommends: (1) initiate all four agents simultaneously or in rapid sequence (e.g. within 1-4 weeks of diagnosis); (2) start at low doses (initiation doses, not target doses); (3) uptitrate each agent in parallel over weeks; (4) close follow-up (1-2 weekly initially — STRONG-HF protocol). SGLT2 inhibitors require no titration (fixed dose), simplifying the process. The rationale: each agent provides independent mortality benefit from the first dose, and the overall effect is synergistic. Delaying any agent delays benefit.

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