What are the next treatment steps for a patient with dilated cardiomyopathy and decreased ejection fractions?

From the Guidelines

The next treatment steps for a patient with dilated cardiomyopathy and decreased ejection fraction should focus on a comprehensive approach including medications, lifestyle modifications, and possibly device therapy, with a primary goal of improving morbidity, mortality, and quality of life.

Medications

First-line medications include ACE inhibitors (such as enalapril 2.5-20 mg twice daily or lisinopril 5-40 mg daily) or ARBs if ACE inhibitors are not tolerated, beta-blockers (such as carvedilol 3.125-25 mg twice daily or metoprolol succinate 12.5-200 mg daily), and mineralocorticoid receptor antagonists (spironolactone 25-50 mg daily) as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. For patients with persistent symptoms, adding an SGLT2 inhibitor like dapagliflozin 10 mg daily or empagliflozin 10 mg daily is recommended. Diuretics such as furosemide 20-80 mg daily should be used as needed for fluid overload. The essential drug treatments for patients with chronic heart failure and a reduced ejection fraction include inhibitors of the renin–angiotensin system, neprilysin inhibitors, beta-adrenergic blockers, and mineralocorticoid receptor antagonists, as supported by the European Journal of Heart Failure 1.

Lifestyle Modifications

Lifestyle modifications including sodium restriction (<2g/day), fluid restriction if needed, regular moderate exercise as tolerated, and avoidance of alcohol are essential components of management. Regular monitoring of renal function, electrolytes, and symptoms is necessary to adjust therapy appropriately.

Device Therapy

For patients with severe symptoms despite optimal medical therapy, consider referral for an implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy (CRT) if QRS duration is prolonged. These medications and therapies work by reducing cardiac workload, preventing adverse remodeling, and improving cardiac function, ultimately aiming to improve patient outcomes in terms of morbidity, mortality, and quality of life. The treatment approach should be guided by the most recent and highest quality evidence, with a focus on individualizing care to meet the specific needs of each patient, as outlined in the 2022 AHA/ACC/HFSA guideline 1.

Some key points to consider in the management of this patient include:

• The importance of titrating medications to target dosing as tolerated, with regular reassessment of symptoms, labs, health status, and LVEF 1.
• The potential benefits of additional therapies, such as hydral-nitrates, in select patients with persistent symptoms despite optimal medical therapy 1.
• The need for ongoing monitoring and adjustment of therapy to optimize patient outcomes and minimize adverse effects. The patient's treatment plan should be regularly reassessed and adjusted as needed to ensure that it remains aligned with the most recent and highest quality evidence, with a focus on improving morbidity, mortality, and quality of life 1.

From the FDA Drug Label

Sacubitril and valsartan tablet is a combination of sacubitril, a neprilisin inhibitor, and valsartan, an angiotensin II receptor blocker, and is indicated: • to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure Benefits are most clearly evident in patients with left ventricular ejection fraction (LVEF) below normal.

The next treatment steps for a patient with dilated cardiomyopathy and decreased ejection fractions are to consider sacubitril-valsartan as it is indicated for reducing the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure, with benefits most clearly evident in patients with left ventricular ejection fraction (LVEF) below normal.

• The recommended starting dosage for adults is 49 mg/51 mg orally twice daily.
• The target maintenance dose is 97 mg/103mg orally twice daily.
• Adjust adult doses every 2 to 4 weeks to the target maintenance dose, as tolerated by the patient 2.

From the Research

Treatment Steps for Dilated Cardiomyopathy

The patient's condition, characterized by dilated cardiomyopathy with decreased ejection fractions of 45% in the left ventricle and 27% in the right ventricle, suggests the need for guideline-directed medical therapies. The following treatment steps can be considered:

• Guideline-Directed Medical Therapies: According to 3 and 4, beta blockers, angiotensin converting enzyme (ACE) inhibitors, and aldosterone antagonists are essential for interrupting deleterious neurohormonal pathways and improving outcomes in patients with heart failure with reduced ejection fraction.
• New Medications: The use of new medications such as ivabradine and sacubitril/valsartan, as discussed in 3, may be beneficial in improving clinical outcomes, including reducing hospitalizations and all-cause mortality.
• Continuation or Initiation of ACEi/ARB: As shown in 5, continuation or initiation of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARB) is crucial for patients with heart failure with reduced ejection fraction, as it is associated with lower mortality and readmission rates.
• Sacubitril/Valsartan Therapy: The case study in 6 demonstrates the effectiveness of sacubitril/valsartan in treating heart failure with reduced ejection fraction, leading to improved clinical status, reduced re-hospitalization rate, and mortality.
• Implantable Cardioverter Defibrillators: As mentioned in 4 and 7, implantable cardioverter defibrillators (ICDs) may be considered for patients with symptomatic heart failure and reduced ejection fraction, although the use of sacubitril/valsartan may impact ICD eligibility.

Considerations for Specific Patient Needs

The patient's unique condition, including the presence of mid-myocardial late gadolinium enhancement and global hypokinesis, should be taken into account when determining the best course of treatment. The following factors should be considered:

• Right Ventricular Pressure Overload: The patient's right ventricular pressure overload and pulmonary hypertension should be addressed through targeted therapies.
• Hypertrophic Cardiomyopathy: Although unlikely in this case, the possibility of hypertrophic cardiomyopathy should be considered and ruled out through further evaluation.
• Sarcoidosis and Other Conditions: The patchy nature of the enhancement in certain areas of the left lateral free wall may suggest sarcoidosis or other conditions, such as Anderson-Fabry disease or Chagas disease, which should be investigated and treated accordingly.