Director @sfhealthnetwork HF Program Zuckerberg SF General Hospital @zsfgcare @ucsfcardiology. New Dad x2! Alum @WUSTLmed⬅️ @UCSFmedicine⬅️ @cornell he/his/him
Is the simultaneous/rapid sequence initiation strategy for GDMT for HFrEF superior to usual care one by one approach?
✅ Better use, dosing, adherence, and persistence
✅ Safe, well tolerated, less HF events
In both the 🏨 and outpatient clinic setting
🎯STRONG-HF
🎯 SHORT
Can quadruple GDMT be simultaneously initiated and rapidly uptitrated in ambulatory outpatients with HFrEF?
The SHORT RCT
✅ Time to quadruple GDMT optimization 29 days vs 112 with usual care
✅ safe, well tolerated, less visits, less HF events
https://t.co/bqJRd3DSYs
Rosuvastatin 20 mg for primary prevention and achieving LDL < 50 mg/dL
Clinical benefits>>potential risks
Relative risk reductions: large
Absolute risk reductions: small per year, but accumulate over time
Cost:
$31.40 per year
$2.61 per month
9 cents a day
💊🫀 What does optimal therapy actually buy a 65-year-old with HFmrEF/HFpEF?
From Nature Medicine (Vaduganathan et al., 2025):
🔴 SGLT2i + nsMRA → +3.6 years event-free survival
🔴 SGLT2i + nsMRA + ARNI → +4.9 years (LVEF <60%)
vs. standard therapy alone.
Nearly 5 extra years without hospitalization or death.
💡 These drugs exist. They work. Are all eligible patients receiving them?
Vaduganathan et al. Nature Medicine, Oct 2025
@mvaduganathan
#HeartFailure #HFpEF #HFmrEF #SGLT2i #ARNI #Cardiology #MedTwitter #NatureMedicine
Every admission = opportunity to improve #GDMTWorks! MD, RN, PharmD, etc; QD-BID labs; vitals 4-6x/day... all hands on deck! Take advantage! Major consequences of stopping or not starting! @SJGreene_md@mvaduganathan@gcfmd@JavedButler1@UCSFIMChiefs
10.1016/j.jchf.2018.06.011
Why are 100% of eligible patients with HFrEF w/o CI or intolerance not receiving quadruple GDMT in 2026?
ARNI+BB+MRA+SGLT2i ➡️
75% ⬇️ all-cause ☠️ (26% ARR, NNT=4, 24 months)
85% ⬇️ HF 🏨 (33% ARR, NNT=3, 24 months)
Extend median survival by 7-11 years
💊 Cost $78/month
Patients newly diagnosed w/ #HFrEF
>9 of 10 deaths occur among pts who never receive ≥1 💊 proven to ⤵️⤵️⤵️death....
...in a nationwide health system w/ minimal or $0 patient copays for #GDMTworks
🤯🤯🤯
@gcfmd@JavedButler1
https://t.co/S1KBq4eVxG
HFrEF in 2026
Most common Rx is use still ACEI/ARB+BB, despite Class 1 recommendation for quadruple GDMT
ACEI/ARB+BB ➡️ ARNI+BB+MRA+SGLTi
Extends median survival:
6.3 years
75.6 months
2300 days
55,188 hours
3,311,280 minutes
💊s cost extra $70 per month
Worth it?
Thankful for my coauthors: Jose Lopez, Andrew Sauer, Jonathan Davis, Nasrien Ibrahim, Rod Tung, Biykem Bozkurt, Gregg Fonarow, and Sana Al-Khatib.
Link: https://t.co/ZdT67WJQhz
I am speaking at UCSF 29th Annual Management of the Hospitalized Patient. Please check out my talk if you're attending the event! #Bob_Wachter#MHP2025 - via #Whova event app
Excited to formally launch our #HeartFailure Clinic at @FollowMercy St. Louis. Offering comprehensive, state-of-the-art, guideline-direct care for anyone with heart failure across the ejection fraction spectrum! #heartfunction#heartsuccess
9/29 I start at Mercy St. Louis!
Working at @UCSFHospitals/@ZSFGCare/@UCSFCardiology was a profound privilege. The community, patients, & colleagues gave me more than I can ever express. Please know how grateful I am to have been part of this extraordinary team.