What is the optimal management plan for a patient with heart failure with reduced ejection fraction (HFrEF) and a history of myocardial infarctions (MIs) on follow-up?

Optimal Management Plan for HFrEF Patients with History of Myocardial Infarctions

The optimal management plan for patients with heart failure with reduced ejection fraction (HFrEF) and a history of myocardial infarctions should include a comprehensive pharmacological regimen with ACE inhibitors/ARBs, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors, along with consideration for device therapy and management of comorbidities. 1

Core Pharmacological Therapy

First-Line Medications (Class I, Level A recommendations)

1. ACE Inhibitor or ARB

   • Start with ACE inhibitor (e.g., lisinopril) at low dose and titrate to target dose
   • For patients with history of MI, ACE inhibitors have shown to reduce mortality and HF hospitalization 1
   • If ACE inhibitor not tolerated (due to cough), switch to ARB
   • Lisinopril has demonstrated decreased pulmonary capillary wedge pressure and systemic vascular resistance while increasing cardiac output 2

2. Beta-Blocker

   • Initiate in stable patients (not during acute decompensation)
   • Target evidence-based beta-blockers (carvedilol, metoprolol succinate, bisoprolol)
   • Start at low dose and gradually titrate up every 2-4 weeks as tolerated
   • Particularly important in post-MI patients 1

3. Mineralocorticoid Receptor Antagonist (MRA)

   • Add for patients who remain symptomatic despite ACE-I/ARB and beta-blocker
   • Monitor potassium and renal function closely
   • Reduces risk of HF hospitalization and death 1

4. SGLT2 Inhibitor

   • Add regardless of diabetes status
   • Recent guidelines (2022) have elevated SGLT2i to a first-line therapy for HFrEF 1
   • Reduces cardiovascular mortality and HF hospitalizations

Second-Line Medications

1. Sacubitril/Valsartan (ARNI)

   • Consider replacing ACE-I/ARB with ARNI in ambulatory patients who remain symptomatic despite optimal therapy with ACE-I/ARB, beta-blocker, and MRA 1
   • Reduces risk of HF hospitalization and death compared to ACE-I alone 3
   • Do not combine with ACE-I (wait 36 hours after last ACE-I dose before starting ARNI)

2. Diuretics

   • Use for symptom relief and management of congestion
   • Adjust dose based on symptoms and signs of congestion
   • Not shown to reduce mortality but improve symptoms and exercise capacity 1

3. Hydralazine and Isosorbide Dinitrate

   • Consider in self-identified Black patients with persistent symptoms despite standard therapy
   • Also an option for patients who cannot tolerate ACE-I/ARB/ARNI due to renal dysfunction or hyperkalemia

Device Therapy Considerations

1. Implantable Cardioverter-Defibrillator (ICD)

   • Recommended for primary prevention in patients with LVEF ≤30% who are at least 40 days post-MI and on optimal medical therapy 1
   • For secondary prevention in those with history of ventricular arrhythmias causing hemodynamic compromise

2. Cardiac Resynchronization Therapy (CRT)

   • Consider in patients with LVEF ≤35%, sinus rhythm, left bundle branch block, and QRS duration ≥130 ms who remain symptomatic despite optimal medical therapy

Follow-up and Monitoring

1. Regular Assessment

   • Monitor symptoms, vital signs, weight, and volume status
   • Check renal function and electrolytes within 1-2 weeks of medication initiation or dose changes
   • Assess for medication side effects and adherence

2. Cardiac Imaging

   • Transthoracic echocardiography (TTE) recommended for assessment of cardiac structure and function 1
   • Consider reassessment of LVEF after optimization of medical therapy (typically 3-6 months)

3. Biomarker Monitoring

   • Consider natriuretic peptide levels to guide therapy in selected patients

Management of Comorbidities

1. Coronary Artery Disease

   • Consider coronary angiography when ischemia may be contributing to HF 1
   • Optimize anti-ischemic therapy
   • Statin therapy recommended post-MI

2. Hypertension

   • Aggressive blood pressure control to prevent HF progression 1
   • Target BP <130/80 mmHg if tolerated

3. Atrial Fibrillation

   • Rate control strategy
   • Anticoagulation based on stroke risk assessment

Common Pitfalls and Caveats

• Underutilization of GDMT: Studies show that many eligible patients do not receive optimal GDMT in clinical practice 4, 5. Ensure all four medication classes are considered.

• Inadequate Dose Titration: Many patients remain on suboptimal doses. Aim for target doses used in clinical trials whenever possible 5.

• Hypotension Concerns: Start with low doses and titrate gradually. Prioritize beta-blockers and ACE-I/ARBs if blood pressure is a limiting factor.

• Renal Function Monitoring: Close monitoring of renal function and electrolytes is essential, particularly when using ACE-I/ARBs, MRAs, and SGLT2i in combination.

• Medication Sequencing: There is no universal agreement on medication sequencing, but generally start with ACE-I/ARB and beta-blocker, then add MRA and SGLT2i.

• Patient Adherence: Poor adherence is common. Simplify regimens when possible and educate patients about the importance of medication adherence 6.

• Specialist Referral: Consider referral to HF specialist for patients not responding to therapy or those who may benefit from advanced therapies 1.

By implementing this comprehensive management plan, patients with HFrEF and history of MI can experience significant reductions in mortality and HF hospitalizations while improving quality of life.