What is the next appropriate step in the treatment plan for a patient with a declined Ejection Fraction (EF) from 63% to 40% and a pacemaker?

From the Guidelines

The next appropriate step for a patient with a declined ejection fraction from 63% to 40% with a pacemaker is to initiate guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF), as recommended by the most recent guidelines 1.

Key Components of GDMT

• Starting an angiotensin-converting enzyme inhibitor (ACEI) such as lisinopril 5-10mg daily or an angiotensin receptor blocker (ARB) like losartan 25-50mg daily if ACEI is not tolerated, as supported by studies 1
• Initiating a beta-blocker such as carvedilol 3.125mg twice daily or metoprolol succinate 25mg daily and gradually uptitrating as tolerated, as recommended by guidelines 1
• Considering a mineralocorticoid receptor antagonist (MRA) like spironolactone 25mg daily, especially if symptoms persist, as suggested by evidence 1

Additional Considerations

• Comprehensive evaluation to determine the cause of EF decline, including:
  • Coronary artery disease assessment
  • Valve function evaluation
  • Review of the pacemaker settings and percentage of ventricular pacing
• Upgrading to a cardiac resynchronization therapy (CRT) device may be beneficial if the patient has a high burden of right ventricular pacing (>40%), as recommended by guidelines 1

Monitoring and Follow-up

• Regular monitoring of renal function, electrolytes, and blood pressure is essential when initiating these medications
• Follow-up echocardiography in 3-6 months to assess response to therapy, as supported by studies 1

From the FDA Drug Label

In two placebo controlled, 12-week clinical studies compared the addition of lisinopril up to 20 mg daily to digitalis and diuretics alone. The combination of lisinopril, digitalis and diuretics reduced the following signs and symptoms of heart failure: edema, rales, paroxysmal nocturnal dyspnea and jugular venous distention A large (over 3,000 patients) survival study, the ATLAS Trial, comparing 2. 5 mg and 35 mg of lisinopril in patients with systolic heart failure, showed that the higher dose of lisinopril had outcomes at least as favorable as the lower dose

The next appropriate step in the treatment plan for a patient with a declined Ejection Fraction (EF) from 63% to 40% and a pacemaker is to optimize heart failure management.

• Consider adding or adjusting medications such as ACE inhibitors (e.g., lisinopril) to reduce symptoms and slow disease progression, as the patient's condition has worsened.
• Monitor the patient's condition closely, as the decline in EF is significant, and adjust the treatment plan accordingly.
• The patient's stable function and pacemaker should be taken into account when making any changes to the treatment plan 2.

From the Research

Patient Treatment Plan

The patient's declined Ejection Fraction (EF) from 63% to 40% and the presence of a pacemaker indicate a need for careful management of heart failure.

• The patient's current EF of 40% falls into the category of Heart Failure with Reduced Ejection Fraction (HFrEF) 3.
• According to recent studies, treatment strategies for HFrEF include the use of diuretics to relieve symptoms, as well as disease-modifying drug and device therapies 3.
• Unless there are specific contraindications, patients with HFrEF should be treated with a β-blocker and one of an angiotensin receptor-neprilysin inhibitor, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker as foundational therapy 3.

Medication Management

• The use of ACE inhibitors has been shown to reduce mortality, reduce hospitalization, reduce symptoms, and increase exercise capacity in patients with heart failure and a low ejection fraction 4.
• Beta-blockers have also been found to improve left ventricular function in patients with heart failure, with a mean increase in EF of 7.4 EF units for metoprolol and 5.7 EF units for carvedilol 5.
• The combination of a diuretic and an ACE inhibitor is currently the proper treatment of congestive heart failure, with a beta-blocker added in selected patients 4.

Device Therapies

• The patient has already received a pacemaker, which can help improve heart function and reduce symptoms 6.
• Other device therapies, such as cardiac resynchronization therapy, transcatheter mitral valve repair, and implantable cardiac defibrillators, may be beneficial in specific subpopulations of patients with HFrEF 3.

Ongoing Management

• The patient's stable function, as indicated by the provider comments, suggests that the current treatment plan is effective 6.
• However, ongoing management and monitoring are crucial to ensure that the patient's condition does not worsen, and to adjust the treatment plan as needed 6, 3.