More than 150 000 people in British Columbia live with heart failure.[1] Considering that approximately half of all individuals with heart failure have heart failure with reduced ejection fraction (HFrEF), this translates to over 75 000 people in BC affected by HFrEF.[2]

The Canadian Cardiovascular Society’s 2021 guidelines recommend treating HFrEF with four classes of medications, collectively referred to as guideline-directed medical therapy (GDMT):

• One of an angiotensin receptor-neprilysin inhibitor, an angiotensin-converting enzyme inhibitor, or an angiotensin receptor blocker.
• A beta-blocker.
• A mineralocorticoid receptor antagonist.
• A sodium-glucose cotransporter-2 inhibitor.[3]

To significantly reduce cardiovascular mortality and heart failure–related hospitalizations and improve symptoms and quality of life, patients with HFrEF should receive the four standard therapies, in the absence of contraindications.[3]

Despite the well-established benefits of GDMT, it remains underused in BC. Current estimates indicate that only one in four eligible patients with HFrEF is receiving all four recommended medication classes.[4]

HFrEF management gaps

Cardiac Services BC’s provincial heart failure community of practice consists of physicians, nurse practitioners, pharmacists, and nurses. They identified the need for a practical tool for clinicians to guide rapid and safe titration of the four GDMT medication classes, as well as a concise, accessible educational resource for patients with HFrEF.

In response to these needs, Cardiac Services BC developed a tool kit of user-friendly resources designed to support BC health care providers with safe, timely, and effective prescribing of medications for HFrEF.

HFrEF GDMT tool kit

The GDMT tool kit (available at www.cardiacbc.ca/clinical-resources/heart-failure#toolkit) includes the following resources:

• GDMT Initiation and Titration Pathway: The pathway provides prescribers and their clinical teams with practical, evidence-based strategies to initiate and titrate all four guideline-recommended medications for HFrEF within 3 months. It also provides recommendations for managing hyperkalemia and renal dysfunction and for administering additional individualized therapies beyond quadruple therapy. The pathway is available in a Supplementary Information file at bcmj.org.
• Guidance for the Use of the HFrEF GDMT Pathway: This resource supports clinicians in applying the GDMT Initiation and Titration Pathway in clinical practice. It highlights key components of the pathway and includes practical tips such as approaches for medication affordability.
• Medications for Heart Failure with Reduced Ejection Fraction (EF): Developed in partnership with the HeartLife Foundation, a patient-led advocacy and support organization, this educational handout supports clear, consistent, and respectful communication with patients and caregivers. It is available in English, French, Arabic, Farsi, Punjabi, Simplified Chinese, Traditional Chinese, Spanish, and Tagalog.

The GDMT tool kit is currently being implemented across BC’s Heart Function Clinics and disseminated in both specialty and primary care settings. Patients with HFrEF benefit from optimized GDMT, and all practitioners in BC, including family physicians and nurse practitioners, are now eligible to prescribe these medications and obtain Fair PharmaCare coverage through Special Authority application. We strongly encourage BC prescribers to review and use the GDMT tool kit in their practice.

Support for BC prescribers

Cardiac Services BC is available to provide educational presentations and support to BC health care providers and their teams. Contact Ms Valerie Barrette, provincial clinical nurse specialist, at valerie.barrette@phsa.ca to request an education session for your group.

Competing interests

Dr Hawkins is on the advisory boards of GSK and Novo Nordisk, has received speakers bureau and honoraria from AstraZeneca, has consulted for AstraZeneca and Roche, has received grants and research support from AstraZeneca, and has been involved with a clinical trial involving AstraZeneca. No other authors declared competing interests.

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This article has been peer reviewed.

References

1.    BC Centre for Disease Control. Chronic disease dashboard. Accessed 12 February 2026. www.bccdc.ca/health-professionals/data-reports/chronic-disease-dashboard#Dashboard.

2.    Becher PM, Lund LH, Coats AJS, Savarese G. An update on global epidemiology in heart failure. Eur Heart J 2022;43:3005-3007. https://doi.org/10.1093/eurheartj/ehac248.

3.    McDonald M, Virani S, Chan M, et al. CCS/CHFS heart failure guidelines update: Defining a new pharmacologic standard of care for heart failure with reduced ejection fraction. Can J Cardiol 2021;37:531-546. https://doi.org/10.1016/j.cjca.2021.01.017.

4.    Cardiac Services BC. Guideline-directed medical therapy (GDMT) rates for heart failure incident cases with estimated reduced ejection fraction, fiscal year 2022/2023. Unpublished internal data. August 2025. Accessed 21 August 2025.

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Dr Diamant is medical chair in heart failure and chronic cardiovascular disease for Cardiac Services BC, heart function clinic physician lead and an advanced heart failure cardiologist at Royal Columbian Hospital, and a clinical assistant professor in the Faculty of Medicine at the University of British Columbia. Dr Hawkins is medical lead, quality and research, at Cardiac Services BC and a clinical associate professor at UBC. Ms Barrette is a provincial clinical nurse specialist at Cardiac Services BC. Ms Chaube is provincial clinical initiatives lead at Cardiac Services BC. Ms Munday is a project manager, research and knowledge exchange, at Cardiac Services BC. Ms Mackay is senior director, provincial quality, research, and integrated care, at Cardiac Services BC.

Corresponding author: Ms Valerie Barrette, valerie.barrette@phsa.ca.