GDMT, or guideline-directed medical therapy, is a form of treatment for people with heart failure with reduced ejection fraction. Doctors prescribe a combination of drugs to treat people’s different symptoms.

Heart failure is a progressive disease for which there is no cure. However, people who take their medications and make healthy lifestyle choices can maintain a high quality of life.

The American Heart Association (AHA) explains that heart failure is when the heart cannot pump enough blood around a person’s body to keep their organs and cells supplied with oxygen and nutrients. It usually affects the left side of a person’s heart first.

Doctors can measure the amount of blood a person’s left ventricle pumps out with each heartbeat. They express this as a percentage called the ejection fraction.

According to the Heart Failure Society of America (HFSA), a healthy heartbeat pumps about 60% of blood from the ventricle. However, if this percentage drops below, or is equal to, 40%, doctors will diagnose a person with heart failure with a reduced ejection fraction (HFrEF).

Guideline-directed medical therapy (GDMT) helps doctors treat people with HFrEF.

This article explains what GDMT for heart failure is, and the types of medications used.

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According to an article published in the AHA’s journal, Circulation, GDMT is part of the clinical practice guidelines for doctors treating people with HFrEF.

Clinical practice guidelines help doctors standardize treatments for medical conditions, ensuring that everyone has access to the best possible treatment for their condition.

GDMT for people with HFrEF includes the use of four different heart medications. It also includes recommendations for implantable cardioverter defibrillators (ICDs).

When a person has heart failure, their heart beats faster than usual, which can cause an irregular heart rhythm. An ICD monitors a person’s heartbeats and delivers an electric shock if their rhythm is dangerously fast. The shock restores a normal heartbeat.

Everyone with HFrEF benefits from GDMT, as it allows access to standardized care across the United States and Europe.

A 2021 study published in the journal Clinical Cardiology found that the absence of GDMT increased the risk of a person dying from HFrEF by 29%.

The guidelines also help doctors keep up to date with medical advances and changes in drug prescription protocols.

Doctors can prescribe some GDMT medications without admitting a person to a hospital.

The clinical practice guidelines recommend using medication before a person has surgery to fit an ICD. If doctors recommend surgery, the person will need a hospital stay.

Medical advances mean that many people using GDMTs can manage their symptoms without an ICD. A 2022 study says more research is necessary to determine whether drugs alone can improve a person’s outlook.

GDMT for HFrEF includes four different classes of medication.

These include beta-blockers, angiotensin receptor neprilysin inhibitors, mineralocorticoid receptor antagonists, and sodium glucose cotransporter-2 inhibitors.


Beta-blockers work by slowing a person’s heart rate and reducing the force with which their heart pumps. This can help lower a person’s blood pressure.

A 2021 study published in the Journal of Cardiovascular Development and Disease identifies beta-blockers suitable for HFrEF. These are:

The U.S. guidelines do not include nebivolol, but the European guidelines do include it.

Angiotensin receptor neprilysin inhibitors

Sacubitril/valsartan is the first angiotensin receptor neprilysin inhibitor (ARNI) to gain approval from the Food and Drug Administration (FDA), and doctors can prescribe it for people with HFrEF. Entresto is its common brand name.

The active components of sacubitril/valsartan work in different ways. Sacubitril reduces the levels of sodium and water in a person’s urine, while valsartan blocks a hormone called angiotensin II. Together, these drugs reduce strain on the heart.

Mineralocorticoid receptor antagonists

Mineralocorticoid receptor antagonists (MRAs) are also known as aldosterone antagonists. Doctors often prescribe spironolactone (Aldactone) or eplerenone (Inspra).

These drugs are diuretics or water pills.

Sodium glucose cotransporter-2 inhibitors

Doctors usually prescribe sodium glucose cotransporter-2 (SGLT-2) inhibitors to help people with type 2 diabetes regulate their glucose levels, but studies show it can also help people with HFrEF.

The AHA reports that one SGLT-2 inhibitor, dapagliflozin reduces a person’s risk of death and prevented their heart failure from getting worse.

The AHA recommends lifestyle changes to help people manage their heart failure at home, including:

  • eating a heart-healthy diet with plenty of fruit and vegetables, whole grains, low fat dairy products, and lean proteins
  • being more physically active by exercising daily
  • maintaining a moderate weight
  • quitting or limiting smoking
  • avoiding or limiting alcohol
  • avoiding or limiting caffeine
  • looking out for sudden weight changes — notify a doctor if you experience a change of more than 3 pounds (lb) in a day or 5 lb in a week

Taking medicines as prescribed can help a person manage their symptoms of heart failure.

Cutting back on fluids and reducing a person’s sodium intake may also help.

Some people with heart failure may need ICDs or even a heart transplant.

According to a 2022 review published in The American Journal of Managed Care, some people experience adverse side effects from GDMT medications. These include dizziness, a slow heart rate, abnormally low blood pressure, and kidney damage. People with these symptoms should talk with a doctor immediately.

HFrEF is a progressive disease, so people need to monitor their symptoms and report any changes to a healthcare professional immediately. According to the AHA, changes include:

  • rapid weight gain, especially if more than 3 lb in one day
  • swelling in the legs and ankles or abdomen
  • shortness of breath, particularly when resting
  • fatigue
  • a loss of appetite
  • a dry cough

While there is no cure for heart failure, medication and lifestyle changes can delay its progression.

Studies show that GDMT can treat a person’s symptoms effectively. Studies also show that people who do not control their symptoms using GDMT have a 29% higher risk of mortality over a 2-year period.

GDMT stands for guideline-directed medical therapy, which is clinical practice guidelines.

GDMT for heart failure is a drug-based therapy using a combination of up to four heart medications.

Studies show that GDMT for heart failure is effective and provides a foundation for doctors to treat people with HFrEF.