What is the initial treatment for a patient with mild heart failure and reduced ejection fraction?

Initial Treatment for Mild Heart Failure with Reduced Ejection Fraction

The initial treatment for patients with mild heart failure and reduced ejection fraction should be a combination of an ACE inhibitor and a beta-blocker, as these medications have been proven to reduce mortality and hospitalization rates. 1

First-Line Pharmacological Therapy

ACE Inhibitors

• Start with a low dose and titrate upward to target dose as tolerated
• Examples of ACE inhibitors and target doses:
  • Enalapril: Target 10-20 mg twice daily 2
  • Lisinopril: Target 20-40 mg daily
  • Ramipril: Target 5 mg twice daily
• Monitor renal function and electrolytes before starting therapy, 1-2 weeks after each dose increase, at 3 months, and then every 6 months 3

Beta-Blockers

• Should be initiated alongside ACE inhibitors in stable patients
• Start with very low doses and titrate gradually upward 3
• Evidence-based beta-blockers and target doses:
  • Bisoprolol: Start 1.25 mg, target 10 mg daily
  • Metoprolol succinate: Start 12.5-25 mg, target 200 mg daily
  • Carvedilol: Start 3.125 mg, target 25-50 mg daily (depending on weight)
  • Nebivolol: Start 1.25 mg, target 10 mg daily 3

Second-Line Therapy (If Patient Remains Symptomatic)

Mineralocorticoid Receptor Antagonists (MRAs)

• Add an MRA (e.g., spironolactone or eplerenone) if the patient remains symptomatic despite treatment with an ACE inhibitor and beta-blocker 1
• Monitor potassium levels closely to avoid hyperkalemia 3

ARNI (Sacubitril/Valsartan)

• Can replace ACE inhibitor in patients who remain symptomatic despite optimal treatment with an ACE inhibitor, beta-blocker, and MRA 1
• Requires a 36-hour washout period when switching from an ACE inhibitor to avoid angioedema 4
• Has shown greater reduction in mortality and hospitalization compared to ACE inhibitors alone 1

Diuretic Therapy

• Diuretics should be prescribed for patients with signs or symptoms of fluid overload to improve symptoms and exercise capacity 1
• Loop diuretics (e.g., furosemide) are preferred for patients with HFrEF
• Thiazide diuretics should only be used if GFR is >30 mL/min 3
• For insufficient response, consider:
  • Increasing diuretic dose
  • Combining loop diuretics with thiazides
  • Administering loop diuretics twice daily 3

Important Considerations

Medications to Avoid

• Diltiazem or verapamil are contraindicated in HFrEF as they increase the risk of worsening heart failure 1
• NSAIDs should be avoided in patients on ACE inhibitors/ARBs 3
• Do not combine an ARB with both an ACE inhibitor and an MRA due to increased risk of renal dysfunction and hyperkalemia 1

Monitoring and Follow-up

• Regular assessment of:
  • Blood pressure
  • Renal function
  • Electrolytes (particularly potassium)
  • Clinical symptoms and functional status
• If hypotension occurs with beta-blockers, reduce vasodilator dose first 3
• If heart failure worsens during beta-blocker titration, increase diuretics or ACE inhibitors before reducing beta-blocker dose 3

Device Therapy Considerations

For patients who remain symptomatic despite 3 months of optimal medical therapy:

• Consider ICD for patients with LVEF ≤35% and NYHA Class II-III symptoms who are expected to survive >1 year with good functional status 1
• Consider CRT for patients with LVEF ≤35% in sinus rhythm with QRS duration ≥150 msec and LBBB morphology 1

Management Algorithm

1. Confirm HFrEF diagnosis (LVEF <40-45%)
2. Start ACE inhibitor and beta-blocker simultaneously at low doses
3. Titrate doses upward every 2-4 weeks as tolerated
4. Add diuretics if signs/symptoms of congestion present
5. If patient remains symptomatic after optimal doses of ACE inhibitor and beta-blocker, add MRA
6. Consider switching from ACE inhibitor to ARNI if patient remains symptomatic despite optimal triple therapy
7. Evaluate for device therapy after 3 months of optimal medical therapy if LVEF ≤35%

Following this evidence-based approach will help reduce mortality, decrease hospitalizations, and improve quality of life in patients with mild heart failure and reduced ejection fraction.