Treatment of heart failure has evolved over the last 
few years. The initiation of the four pillars of HF 
medical therapy is emphasized in international 
guidelines. Guideline-Directed Medical Therapy 
(GDMT) for HFrEF has reduced morbidity, mortality, 
and hospital admissions. A focused update published 
in 2023 emphasized the role of sodium-glucose 
cotransporter-2 inhibitors (SGLT2i) initiation in both 
HFrEF and HFmrEF. Cardiopulmonary bypass during 
cardiac surgery is associated with alteration in the 
homeostasis. This includes volume overload, acute 
kidney injury, low cardiac output, and heart block. 
This usually hinders the early initiation of GDMT.