A 45-year-old woman with newly diagnosed dilated cardiomyopathy (LVEF 22%) is initiated on guideline-directed medical therapy (GDMT). Which of the following is the CORRECT sequence of initiating GDMT based on contemporary evidence?

• A Simultaneous initiation of low doses of ACE inhibitor/ARB/ARNI + beta-blocker + MRA + SGLT2 inhibitor, then uptitrate ✓
• B Loop diuretic first → ACE inhibitor → beta-blocker → MRA → SGLT2 inhibitor
• C ACE inhibitor alone for 3 months before adding beta-blocker to avoid haemodynamic deterioration
• D IV inotropes first to stabilise LVEF before starting oral GDMT

Explanation

The STRONG-HF trial and contemporary ACC/AHA 2022 HF guidelines support rapid simultaneous initiation of all four pillars of GDMT (RAAS blocker/ARNI, beta-blocker, MRA, and SGLT2 inhibitor) at low doses with early uptitration, rather than sequential addition. This approach has been shown to reduce 180-day all-cause death and HF readmission. The old sequential approach (waiting weeks between adding each drug) delays prognostic benefit. Diuretics relieve congestion but are not GDMT per se.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.