Core IM | Internal Medicine Podcast #135 Guideline Directed Medical Therapy Part II: 5 Pearls Segment
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Sep 20, 2023 Discussion on starting, continuing, and stopping GDMT medications for heart failure patients with kidney disease. Exploring the use of hydralazine and isosorbide dinitrate in hypertension management. Insights on ivabradine as a medication for heart failure. Considerations for starting GDMT inpatient versus outpatient. Addressing the question of EF recovery in patients on GDMT.
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GDMT in CKD Overview
- Beta blockers do not affect kidney function and can be pushed to max dose unless patient is orthostatic.
- ACE inhibitors, ARBs, MRAs, and SGLT2 inhibitors have kidney-related thresholds but can often be continued with close monitoring.
Hydralazine and Isosorbide Dinitrate Traits
- Hydralazine and isosorbide dinitrate lower blood pressure by vasodilation without affecting kidney function or potassium directly.
- Their dosing is limited by headaches and the need for three times daily administration, which affects tolerability.
Hydral Isosorbide Trial Insights
- Data supporting hydralazine and isosorbide dinitrate mainly comes from older trials focused on African American populations.
- There's no definitive evidence hydralazine and isosorbide dinitrate benefit only African Americans; etiology of cardiomyopathy may be more relevant.