Effective management of decompensated heart failure with reduced ejection fraction (HFrEF) remains a clinical challenge, particularly regarding early initiation of guideline-directed medical therapy (GDMT). ESC 2025 highlighted a prospective observational cohort study of 203 hospitalized HFrEF patients evaluating the impact of the four pillars of HF therapy—ACEi/ARB/ARNI, beta-blockers, MRAs, and SGLT2 inhibitors—on hemodynamic and biological parameters. 

Patients were divided into two groups: Group A, not receiving any pillars prior to admission, and Group B, already on at least one therapy. During hospitalization, Group A initiated all four pillars, while Group B had therapy optimized. Both groups experienced significant improvements in systolic and diastolic blood pressure, heart rate, and weight. Group A showed notable improvement in NYHA functional class, with a shift from predominantly class III/IV to class II/III at discharge. MRAs and SGLT2i use increased substantially in Group B. Serum creatinine, sodium, and potassium remained stable, and 30-day mortality was similar between groups.

These findings underscore that early, aggressive implementation of HF therapy during hospitalization is safe and enhances clinical outcomes and functional capacity in HFrEF patients.