Guideline-Directed Medical Therapy in Heart Failure

Heart failure is one of the most common, costly and consequential conditions afflicting our patients. It is also one of the most actionable. A well-established combination of four commonly prescribed medications can reduce heart failure admissions by as much as 60–70% when used together.

Despite now having a mature, evidence-based therapeutic framework—guideline-directed medical therapy (GDMT)—that dramatically improves survival, reduces hospitalizations and enhances quality of life, consistent delivery remains elusive. The gap between what we know and what we do continues to define the opportunity.

The Science Is Clear

Over the past two decades, clinical trials and guideline updates from the American Heart Association and American College of Cardiology have established a four-pillar foundation for patients with heart failure with reduced ejection fraction (HFrEF):

• ARNI (preferred) or the less expensive ACE inhibitor/ARB, which are only incrementally worse than ARNI
• Evidence-based beta blocker
• Mineralocorticoid receptor antagonist (MRA)
• SGLT2 inhibitor

These therapies are complementary and synergistic. When used together, they reduce mortality by more than 60% and significantly decrease heart failure hospitalizations. Benefits are seen early and extend across comorbid conditions, including diabetes and chronic kidney disease.

This is not a marginal gain—it is one of the highest-value interventions in modern medicine.

The Performance Gap

Despite strong evidence and clear guidelines, real-world performance lags:

• 89% of eligible patients are not on appropriate GDMT
• Dose optimization is inconsistent
• Time to initiation is often prolonged
• Longitudinal titration is unreliable

This is not a knowledge problem. It is a delivery problem.

Why GDMT Is Central to Population Health and Value-Based Care

Heart failure costs are driven largely by acute utilization—particularly hospital admissions and readmissions. GDMT directly targets this driver:

• Fewer hospitalizations
• Slower disease progression
• Improved functional capacity
• Increased survival

This translates directly into performance: better outcomes at lower total cost of care. For clinically integrated networks like OHN, GDMT is therefore not simply a clinical priority—it is a core operational competency.

From Physician-Dependent to System-Enabled Care

Traditional models rely on individual clinicians to initiate and titrate therapy during episodic visits. This approach is inherently limited for a condition that requires continuous optimization.

High-performing systems redesign care to ensure reliability at scale.

Key capabilities include:

• Standardized Pathways
  
  • Clear, evidence-based protocols for initiation, sequencing and titration reduce variation and accelerate adoption.
• Team-Based Execution
  
  • Pharmacists, APPs and care managers can lead titration workflows, monitor labs and manage side effects—freeing physicians to focus on diagnosis and complex care decisions.
• Longitudinal Management
  
  • GDMT optimization happens between visits. Remote monitoring, asynchronous communication and proactive outreach are essential.
• Data-Driven Gap Closure
  
  • Population health tools should identify patients not on therapy, not at target dose or lost to follow-up—enabling focused intervention.
• Embedded Decision Support
  
  • Clinical decision support integrated into the workflow reduces friction and translates guidelines into real-time action.

GDMT Efforts Currently Underway

To that end, we would like to call your attention to a few efforts that are already underway to increase rates of GDMT across the system. An initiative called Comprehensive Care Model Redesign focuses on reducing admissions, readmissions and ER visits for both CKD and heart failure patients. This effort is composed of a multidisciplinary team of stakeholders working together to identify opportunities to improve rates of GDMT across inpatient, post-acute and outpatient components of the system. As part of this effort, Stephen Lambert, MD, has created a dynamic SmartSet for patients with heart failure that helps guide clinicians toward appropriate GDMT along with its corresponding labs and other monitoring studies. And within Epic, there will also be an optimized practice advisory (OPA) to help clinicians identify opportunities for appropriate GDMT by updating the nomenclature and diagnostic codes across specific types of heart failure.

Network Participation Opportunity—CHF SmartSet Webinar

The primary care CHF SmartSet has been updated to support guideline-directed medical therapy (GDMT) for heart failure, helping streamline evidence-based treatment and ordering workflows. Providers on Ochsner’s instance of Epic are encouraged to log in to OHN’s Network Education Portal to watch the CHF SmartSet webinar.

Webinar: OHN Physician Education - CHF Smart Set
*Recommended for providers on Ochsner’s instance of Epic*
Eligible (OHN) Education Points – 10
Duration – 51 minutes

Coming Soon—Webinar: Guideline-Directed Medical Therapy for Heart Failure
Recommended for all CIN and ACO providers
Presenter – Kenny Cole, MD

A Defining Opportunity for OHN

Clinically integrated networks are uniquely positioned to operationalize GDMT across populations. By aligning incentives, standardizing care and investing in infrastructure, CINs can transform GDMT from an aspirational guideline into a reliably delivered standard. This is where value-based care becomes tangible. GDMT for heart failure represents an alignment of clinical excellence and economic value. We have the evidence. We have the therapies. What remains is execution. Closing the GDMT gap is about designing systems that make the right care the default. For organizations committed to population health, the opportunity now is to ensure that GDMT is delivered reliably, systematically and at scale across every eligible patient.