From the Guidelines
For a patient with an ejection fraction (EF) of 20% admitted to the hospital for chest pain, the follow-up visit should prioritize optimization of heart failure management, including the use of ACE inhibitors or ARBs, as recommended by the 2017 ACC/AHA/HFSA guideline 1. The patient should schedule an appointment with their cardiologist within 1-2 weeks of discharge. During this visit, expect a comprehensive evaluation including a physical exam, review of medications, and discussion of symptoms. The doctor will likely order follow-up tests such as an echocardiogram to reassess heart function, and possibly stress testing or other imaging if needed. Be prepared to discuss any symptoms like shortness of breath, chest pain, swelling, or fatigue. Bring a list of all medications being taken and any side effects experienced. An EF of 20% indicates significant heart dysfunction (heart failure with reduced ejection fraction), which requires close monitoring and medication adjustment. The use of ACE inhibitors has been shown to reduce morbidity and mortality in patients with HFrEF, as established by randomized controlled trials 1. Alternatively, ARBs can be used, especially in patients who are intolerant to ACE inhibitors, as they have also been shown to reduce morbidity and mortality in HFrEF patients 1. The 2016 ESC guidelines also support the use of ACE inhibitors and beta-blockers in patients with symptomatic heart failure with reduced ejection fraction 1. Regular follow-up care is crucial as proper management can improve symptoms, quality of life, and potentially help heart function recover over time. Lifestyle modifications, including sodium restriction, fluid management, daily weight monitoring, and appropriate exercise, should also be discussed during the follow-up visit. The goal of follow-up care is to optimize heart failure management, reduce the risk of hospitalization and death, and improve the patient's quality of life. The patient's medication regimen should be optimized to include an ACE inhibitor or ARB, in addition to a beta-blocker, to reduce the risk of HF hospitalization and death, as recommended by the guidelines 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Follow-up Visit for Chest Pain with EF of 20%
Given an ejection fraction (EF) of 20% and admission to the hospital for chest pain, the following steps can be considered for a follow-up visit:
- Review of medication regimen:
- Consideration of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) and beta-blockers as guideline-recommended first-line therapies for heart failure with reduced ejection fraction (HFrEF) 2
- Potential addition of an aldosterone receptor antagonist, such as spironolactone or eplerenone, to the treatment regimen 3
- Optimization of existing medications:
- Up-titration of beta-blockers and ACEi/ARB to achieve guideline-recommended target doses, as this has been associated with improved outcomes in HFrEF patients 2
- Monitoring and assessment:
Considerations for Specific Medications
- Beta-blockers: may reduce the risk of cardiovascular mortality in heart failure patients, but further trials are needed to confirm this benefit 4
- ACEi/ARB: likely have little or no effect on cardiovascular mortality and quality of life in heart failure with preserved ejection fraction (HFpEF), but may be beneficial in HFrEF 2, 4
- Aldosterone receptor antagonists: may reduce heart failure hospitalization, but have little or no effect on cardiovascular mortality and quality of life in HFpEF 4
- SGLT2 inhibitors: may reduce heart failure events in patients with HFmr/pEF, and their combination with aldosterone antagonists is being investigated in ongoing trials 6