Heart failure (HF) remains a leading cause of morbidity and mortality, but timely initiation and optimization of guideline-directed medical therapy (GDMT) can meaningfully improve outcomes. In patients with HFrEF, comprehensive quadruple therapy—including a RAAS inhibitor, beta-blocker, mineralocorticoid receptor antagonist (MRA), and SGLT2 inhibitor—can reduce mortality by over 70%. Trials such as STRONG-HF have demonstrated that early, in-hospital or post-discharge uptitration lowers rehospitalization and death rates.

Comorbidities—particularly the cardiovascular–kidney–metabolic overlap—complicate management but highlight the need for individualized care. RAAS inhibitors reduce intraglomerular pressure and proteinuria. SGLT2 inhibitors decrease glucose reabsorption and myocardial stress, benefiting patients with or without diabetes. Nonsteroidal MRAs may also reduce renal decline and cardiovascular events in patients with type 2 diabetes and CKD. Therapy decisions must consider renal function, potassium levels, and blood pressure.

Risk stratification with tools such as LVEF, NT-proBNP, and NYHA class can guide therapy intensity and follow-up. For example, elevated NT-proBNP levels post-GDMT initiation are prognostic and can help refine monitoring strategies.

Multidisciplinary HF programs—including pharmacist-led titration, digital tools, and remote monitoring—can reduce readmissions by up to 40% and mortality by 25%.

How can your team best use pharmacist-led or digital titration to accelerate GDMT optimization in HFrEF? What strategies have been effective in overcoming therapeutic inertia and improving adherence?

Congenital heart disease (CHD) remains the leading cause of death from birth defects worldwide. While survival exceeds 90% in high-income countries, many patients—particularly where surgery is limited—rely on pharmacologic management. Treatments often reflect adult heart failure regimens, targeting shared mechanisms like neurohormonal activation and cardiac remodeling.

Highlights:

• ACE inhibitors, ARBs, beta-blockers, and diuretics to manage heart failure and ventricular dysfunction
• Endothelin receptor antagonists, PDE-5 inhibitors, prostaglandins, and sGC stimulators for pulmonary arterial hypertension (PAH)
• Digoxin, antiarrhythmics, and NSAIDs as adjunctive therapies for symptoms, arrhythmias, and ductal patency
• Up to 85% of cardiovascular drugs in children are used off-label due to lack of pediatric-specific trials

What Sets This Study Apart:

This review consolidates pharmacologic strategies tailored to the complexity of CHD across age groups and comorbidities. It emphasizes treatment rationale, dosing nuances, and highlights critical evidence gaps that affect pediatric prescribing.

Limitations:

Current practice leans heavily on adult data. Clinical trials for pediatric CHD are scarce (<0.45% of NIH-funded CV trials), limiting evidence-based dosing, safety, and outcome data in children.

How do you balance limited pediatric trial data with the need for evidence-based care in CHD? What role could personalized, genomics-driven approaches play in shaping future outcomes?