• Heart Failure, Systolic
• Mitral Valve Insufficiency

With recent advancements in the treatment of heart failure with reduced ejection fraction (HFrEF) including the addition of angiotensin receptor–neprilysin inhibitor, sodium–glucose cotransporter 2 inhibitors (SGLT2i) and transcatheter edge-to-edge mitral valve repair (TEER), the treatment of patients with cardiomyopathy and secondary mitral regurgitation (SMR) has become increasingly complex and can lead to suboptimal utilisation of indicated therapies. Tanaka and colleagues1 have provided a real-world analysis of guideline-directed medical therapy (GDMT) among HFREF patients with SMR and managed with TEER. Their findings reinforce the importance of engaging focused heart failure (HF) cardiologists and allied teams to optimise medical therapy before and after TEER. Consistent with the 2021 European Society of Cardiology guideline on HF management,2 the authors define GDMT as modulation of the renin–angiotensin–aldosterone and sympathetic nervous systems with triple therapy including renin–angiotensin system (RAS) inhibitors, beta-blockers (BBs) and mineralocorticoid receptor antagonists (MRAs) noting that SGLT2is were approved after study completion. Their results demonstrated the clinical benefits of maintaining triple therapy neuromodulation following TEER. They have thus provided a pragmatic and simple threshold of GDMT that will undoubtedly improve the care of patients with SMR undergoing TEER.

Tanaka et al retrospectively divided patients with SMR and left ventricular ejection fraction (LVEF) <50% who underwent TEER into GDMT and non-GDMT cohorts. Local heart teams optimised medical therapy and decided when to …