Most people with dilated cardiomyopathy (DCM) are treated with a combination of medications that work together to support the heart, reduce symptoms, and improve long-term outcomes. These medications are not just for managing symptoms; they are designed to protect your heart muscle and help it function better over time, which can improve both quality of life and survival.
The Four Main Medication Groups (the “Four Pillars”)
These four categories are often referred to as Guideline-Directed Medical Therapy (GDMT) or the “Four Pillars” of heart failure treatment. Medications in these four categories are the “gold standard” of care and are often recommended for people with DCM and reduced ejection fraction. They have been well studied and proven to improve outcomes. Not everyone will take every medication, but most people with DCM and reduced ejection fraction benefit from some combination of these four groups.
A Closer Look at the Four Pillars
Pillar 1: ACE Inhibitors, ARBs, or ARNIs
These medications help relax blood vessels, lower blood pressure, and reduce the heart’s workload. They are commonly used to support heart function and may help slow disease progression in some forms of cardiomyopathy.
Examples include:
- ACE inhibitors (like Lisinopril)
- ARBs (like Losartan)
- ARNIs – prevent the breakdown of important protective hormones that help counteract heart failure (such as Sacubitril/Valsartan, brand name Entresto)
These medications help:
- Dilate blood vessels, improve blood flow, and lower blood pressure
- Reduce stress on the heart
- Slow disease progression
Important Safety Note
When switching specifically from an ACE inhibitor (like Lisinopril) to an ARNI (Entresto), a 36-hour gap is required to prevent a serious reaction called angioedema.
Pillar 2: Beta Blockers
These medications help protect the heart by slowing the heart rate and reducing its workload. They may improve heart muscle function, sometimes to normal or near-normal levels. Beta blockers work by blocking adrenaline, a stress hormone that can be harmful to the heart when levels remain high in people with DCM and reduced ejection fraction.
Examples include:
- Metoprolol succinate
- Carvedilol
- Bisoprolol
These medications:
- Help the heart beat more efficiently
- May reduce blood pressure
- Reduce abnormal heart rhythms
- Improve long-term survival
It’s common to feel more tired when first starting or increasing the dose of a beta blocker. This often improves as your body adjusts. Let your care team know if fatigue feels severe or does not improve.
Tip
If your beta blocker makes you sleepy, ask your doctor if you can take it in the evening rather than the morning.
Pillar 3: Mineralocorticoid Receptor Agonists (MRAs)
These medications improve survival and reduce hospitalizations and the risk of sudden cardiac death in people with DCM and reduced ejection fraction.
Examples of MRAs include:
- Spironolactone
- Eplerenone
These medications:
- Help reduce fluid retention
- Lower the risk of hospitalization
- Provide additional heart protection
Important Safety Note
Because MRAs can raise potassium levels, talk to your doctor before using salt substitutes or potassium supplements. Kidney function and potassium levels must be monitored while taking them.
Pillar 4: SGLT2 Inhibitors
These medications reduce the risk of hospitalization for heart failure and cardiovascular death in people with DCM and an ejection fraction of 40% or less.
Examples include:
- Dapagliflozin (Farxiga)
- Empagliflozin (Jardiance)
These medications:
- Reduce hospitalizations for heart failure
- Lower the risk of cardiovascular death
- Improve quality of life
Did You Know?
SGLT2 inhibitors were originally used to treat diabetes, but they are now proven to help people with heart failure, even if they do not have diabetes.
Medication Dosing: Why “Low and Slow” Matters
Most heart failure medications are started at a low dose and increased gradually over time. This helps your body adjust and reduces the risk of side effects.
The goal is to reach a target dose that provides the most benefit, but this process can take weeks or even months. Everyone’s timeline is different.
If your dose is still being adjusted, that does not mean the medication isn’t working or that you are “failing” treatment. Medication adjustments are a normal part of heart failure care.
Be Patient With the Process
Reaching the target dose of heart failure medications is the goal, but it often happens gradually over time. Always follow your doctor’s orders and take medications exactly as prescribed.
Medication Side Effects
All medications can have side effects. Some people experience them, while others do not.
When starting a new medication or changing a dose, you may notice temporary side effects as your body adjusts. Always tell your doctor or care team about any symptoms that concern you.
You should:
- Read the medication label and information sheet
- Ask your doctor what side effects to watch for
- Know when to call the office if symptoms become bothersome or severe
Never stop or change a medication without speaking to your healthcare provider.