SHOULD BE USED ONE AFTER THE OTHER ACCORDING TO THE CLINICAL STAGE AND TESTING TOLERANCE AND CLINICAL RESPONSE 

I think the patient’s clinical state should determine how GDMT should be initiated. Two important factors will be the blood pressure and the patient’s eGFR. For example, if the patient has non-ischemic CMP with severe LV dysfunction and low-normal BP (e.g., 95/60mmHg), I won’t be in a hurry to initiate ARNI/ACEI/ARB. MRA and SGLT2i have less effect on BP in heart failure patients. I will also commence such patients on a low dose beta blocker, slowly titrated up. My approach will differ in a patient with better BP profile who has other contraindication to these 4 meds. For such, the 4 pillars can be initiated at a go. Of course, SGLT2i should not be prescribed in patients with very low eGFR or on dialysis.