In this fourth installment of our heart failure series, we dive into another essential pillar of guideline-directed medical therapy (GDMT): the renin-angiotensin system (RAS) inhibitors. This includes ACE inhibitors, ARBs, and ARNIs—cornerstones of treatment for patients with heart failure with reduced ejection fraction (HFrEF).

Join us as we unpack how RAS inhibitors work, when to initiate therapy, and how to navigate clinical decision-making around switching, tolerability, renal function, and blood pressure thresholds. We also discuss practical considerations for initiating or holding therapy during acute kidney injury (AKI) and the evidence-based rationale for continuing these agents even with declining GFR.

Whether you're managing complex patients in the SNF, at home, or via telemedicine, this episode offers clear, clinically grounded insights to optimize care.

In this episode of Key Perspectives, we continue our heart failure series by diving into Part 3: Medication Management, with a focus on spironolactone, a cornerstone of guideline-directed medical therapy (GDMT).

We start by reviewing the distinctions between HFpEF, HFmrEF, and HFrEF, and discuss how treatment strategies differ across these subtypes. The hosts explain what GDMT is, who develops it, and why it's essential in improving outcomes and reducing hospitalizations in heart failure patients.

The spotlight is on spironolactone—its dual role in HFrEF and HFpEF, its mechanism as a mineralocorticoid receptor antagonist, and how it contributes to diuresis, cardiac remodeling prevention, and potassium-sparing benefits. We also cover clinical pearls, including when it can be used alongside loop diuretics like Lasix, and important considerations for avoiding use in patients with hyperkalemia or poor renal function.

Tune in for a concise, clinically relevant discussion that enhances your understanding of heart failure pharmacology and supports your practice in geriatric and complex patient care settings.

In this episode, we kick off our deep dive into heart failure treatment, starting with a fundamental goal: achieving ideal volume status. Managing fluid overload is crucial for symptom control and preventing hospitalizations — and today, we’re unpacking how to do it effectively.

We'll cover:

• Dry Weight: What it is, why it matters, and how to determine it.

• Fluid Restriction: When and why.

• Loop Diuretics: A comparison of the "Big 3" — Furosemide, Torsemide, and Bumetanide — including dosing strategies and absorption differences.

• Common Adverse Effects: Hypokalemia, renal function changes, and hypotension — what to monitor and how to respond.

• Potassium Supplementation: Should you start it preemptively when initiating a loop diuretic?

🔔 Stay tuned: In future episodes, we’ll continue walking through each major medication class used in heart failure management.