From the Guidelines
For a patient with a left ventricular ejection fraction (EF) of 45-50%, guideline-directed medical therapy (GDMT) should be initiated. The recommended approach includes starting an ACE inhibitor (such as lisinopril 5-10mg daily or enalapril 2.5-5mg twice daily) or an ARB (such as losartan 25-50mg daily) if ACE inhibitors are not tolerated, as supported by the 2022 AHA/ACC/HFSA guideline 1. Beta-blockers should also be prescribed, such as carvedilol (starting at 3.125mg twice daily and titrating up to 25mg twice daily) or metoprolol succinate (starting at 12.5-25mg daily and titrating up to 200mg daily), as recommended by the 2013 ACCF/AHA guideline 1.
Key Considerations
- The initiation of GDMT in patients with an EF of 45-50% is crucial to prevent disease progression and improve outcomes.
- Regular monitoring of blood pressure, heart rate, renal function, and electrolytes is necessary when starting and titrating these medications.
- The selection of specific medications and dosages should be individualized based on patient characteristics and comorbidities.
Medication Selection
- ACE inhibitors or ARBs are recommended as first-line therapy for patients with heart failure with reduced ejection fraction (HFrEF) 1.
- Beta-blockers have been shown to reduce mortality and improve symptoms in patients with HFrEF 1.
- Mineralocorticoid receptor antagonists, such as spironolactone, may be beneficial for patients with persistent symptoms 1.
Rationale
The rationale for initiating GDMT in this EF range is that these patients often progress to more severe heart failure if untreated, and evidence suggests that early intervention can prevent adverse cardiac remodeling, improve symptoms, and reduce the risk of hospitalization and mortality. Although the provided evidence does not directly address the EF range of 45-50%, the principles of GDMT and the importance of early intervention in heart failure management are well-established 1.
From the Research
Guideline-Directed Medical Therapy (GDMT) for Heart Failure with Reduced Ejection Fraction (HFrEF)
The decision to start GDMT for a patient with a left ventricular ejection fraction (EF) of 45-50% depends on various factors, including the presence of symptoms and the patient's overall clinical profile.
- Current Guidelines and Recommendations: According to recent studies 2, GDMT is the cornerstone of pharmacological therapy for patients with HFrEF and consists of four main drug classes: renin-angiotensin system inhibitors, evidence-based β-blockers, mineralocorticoid inhibitors, and sodium glucose cotransporter 2 inhibitors.
- Eligibility for GDMT: A study published in 2019 3 found that approximately 38% of patients with HFrEF were eligible for sacubitril/valsartan treatment, which is a part of GDMT, after being optimized on GDMT.
- Importance of EF in GDMT: Research has shown that EF is a significant predictor of outcomes in patients with HFrEF 4. However, the effectiveness of GDMT, including sacubitril/valsartan, has been demonstrated across the EF spectrum, with no evidence of heterogeneity.
- Initiation and Titration of GDMT: A 2019 study 5 highlighted the importance of a focused GDMT clinic in increasing the proportion of patients with HFrEF on appropriate medications and at target doses. Another study published in 2022 6 emphasized the need for careful consideration when reducing GDMT doses during hospitalization, as this can impact patient outcomes.
- Clinical Considerations: The decision to start GDMT for a patient with an EF of 45-50% should be based on individual clinical assessment, taking into account the presence of symptoms, renal function, blood pressure, and other comorbidities.