From the Guidelines
For a patient with heart failure with reduced ejection fraction (HFrEF) due to hyperthyroidism who has achieved euthyroidism and an ejection fraction (EF) of 64% after treatment with the 4 pillars, discontinuation of the 4 pillars can be considered, as the primary cause has been treated and the heart function has recovered. The patient's current EF of 64% falls into the category of heart failure with preserved ejection fraction (HFpEF) according to the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. However, it is essential to note that the guideline suggests continuing HFrEF treatment for patients who improve their LVEF to >40% and are considered to have HFimpEF. Since the patient's EF has improved to 64%, which is above 50%, the decision to discontinue the 4 pillars should be made on a case-by-case basis, considering the patient's overall clinical condition and other potential indications for these medications. Some key points to consider when deciding whether to continue or discontinue the 4 pillars include:
- The patient's blood pressure and whether they have hypertension that requires treatment with ACE inhibitors, beta-blockers, or other medications
- The presence of other cardiovascular conditions, such as coronary artery disease or atrial fibrillation, that may require ongoing treatment with beta-blockers or other medications
- The patient's kidney function and whether they have any indications for SGLT2 inhibitors, such as diabetes or chronic kidney disease
- The need for regular follow-up echocardiograms to monitor the patient's heart function and adjust treatment as needed. Discontinuation of the 4 pillars, if decided, should be done gradually under medical supervision, starting with the mineralocorticoid receptor antagonist, followed by the SGLT2 inhibitor, then the ACE inhibitor, and finally the beta-blocker, with careful monitoring of blood pressure and kidney function.
From the Research
Heart Failure with Reduced Ejection Fraction (HFrEF) Treatment
The treatment of HFrEF involves the use of four pillars of medical therapy, which include:
- Angiotensin-Converting Enzyme Inhibitors (ACEIs) or Angiotensin Receptor-Neprilysin Inhibitors (ARNIs)
- Beta-Blockers (BB)
- Mineralocorticoid Receptor Antagonists (MRAs)
- Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2is)
Continuation of Treatment
In a patient with HFrEF due to hyperthyroidism who has achieved euthyroidism and an EF of 64% after treatment with the 4 pillars, the decision to continue treatment should be based on individual patient characteristics and response to therapy.
- According to 2, guidelines recommend the immediate initiation of all four class I guideline-directed medical therapies following the diagnosis of HFrEF.
- However, as noted in 3 and 4, concomitant use of all four drug groups in target doses is often limited by intolerance or fear of potential complications.
- The study in 5 highlights the importance of up-titrating beta-blockers to evidence-based target doses, as this can significantly reduce the hazard of death or major adverse cardiac events.
- Additionally, 6 provides an overview of the medical management of patients with HFrEF, emphasizing the role of the four pillars of medical therapy and the importance of individualizing treatment based on patient characteristics and response to therapy.
Key Considerations
When deciding whether to continue treatment with the 4 pillars in a patient with HFrEF due to hyperthyroidism who has achieved euthyroidism and an EF of 64%, the following factors should be considered:
- The patient's individual response to therapy and any potential side effects or complications
- The presence of any comorbidities or concomitant medications that may interact with the 4 pillars
- The patient's current EF and any changes in EF over time
- The potential benefits and risks of continuing or discontinuing treatment with the 4 pillars, as discussed in 2, 3, 4, 5, 6