What is the treatment approach for heart failure staged by ejection fraction (EF)?

Treatment Approach for Heart Failure Staged by Ejection Fraction

The treatment of heart failure should be tailored according to ejection fraction classification, with specific guideline-directed medical therapy (GDMT) for each category to reduce mortality and improve quality of life. 1

Heart Failure Classification by Ejection Fraction

Heart failure is classified into three main categories based on left ventricular ejection fraction (LVEF):

• HF with Reduced Ejection Fraction (HFrEF): LVEF ≤40%
• HF with Mildly Reduced Ejection Fraction (HFmrEF): LVEF 41-49%
• HF with Preserved Ejection Fraction (HFpEF): LVEF ≥50% 2

Treatment Approach for HFrEF (LVEF ≤40%)

First-Line Quadruple Therapy

1. Beta-blockers (start first)

   • Carvedilol: Start 3.125mg BID, target 25mg BID (<85kg) or 50mg BID (≥85kg)
   • Metoprolol succinate: Start 12.5-25mg daily, target 200mg daily
   • Bisoprolol: Start 1.25mg daily, target 10mg daily 1

2. ARNI (Angiotensin Receptor-Neprilysin Inhibitor)

   • Sacubitril/valsartan: Start 24/26mg BID, target 97/103mg BID
   • Preferred over ACE inhibitors due to mortality benefit 1, 3

3. Mineralocorticoid Receptor Antagonists (MRAs)

   • Spironolactone: Start 12.5-25mg daily, target 25-50mg daily
   • Eplerenone: Start 25mg daily, target 50mg daily 1, 4

4. SGLT2 Inhibitors

   • Dapagliflozin: 10mg daily
   • Empagliflozin: 10mg daily 1

Additional Therapies

• Diuretics for fluid overload (pulmonary congestion or peripheral edema)
  • Not shown to reduce mortality but improve symptoms 2
  • Should be administered with ACE inhibitors/ARNIs when possible 2

Special Considerations

• Reduce starting doses by half for patients:
  • Not currently on ACE inhibitor/ARB
  • With severe renal impairment
  • With moderate hepatic impairment 3
• Avoid non-dihydropyridine calcium channel blockers, moxonidine, and alpha-adrenergic antagonists 1

Treatment Approach for HFmrEF (LVEF 41-49%)

This group represents a diverse population including those with improving HFrEF or worsening HFpEF 2, 5.

Recommended Therapy

• Similar approach to HFrEF as these patients may benefit from neurohormonal blockade therapies 5
• Beta-blockers and ACE inhibitors/ARNIs should be used to prevent progression to symptomatic heart failure 2
• Address underlying etiology (ischemia, hypertension, etc.) 5

Treatment Approach for HFpEF (LVEF ≥50%)

HFpEF is more common in elderly women with systolic hypertension 6.

Recommended Therapy

• Control of systolic hypertension is crucial 6
• Diuretics to manage fluid overload and prevent flash pulmonary edema 6
• SGLT2 inhibitors have shown benefit in reducing heart failure hospitalizations 1
• Manage comorbidities (hypertension, diabetes, obesity, atrial fibrillation) 2

Device Therapy and Surgical Interventions

Consider for appropriate patients with persistent symptoms despite optimal medical therapy:

• Cardiac Resynchronization Therapy (CRT): For NYHA class III-IV, LVEF ≤35%, QRS ≥120 ms 1
• Implantable Cardioverter Defibrillator (ICD): For LVEF ≤30-35% for primary prevention 1
• Left Ventricular Assist Device (LVAD): For end-stage heart failure ineligible for transplantation 1
• Heart transplantation: For end-stage heart failure 1

Monitoring and Follow-up

• Regular assessment of symptoms, vital signs, volume status
• Monitor renal function and potassium levels
• Assess for medication side effects (hypotension, hyperkalemia)
• Consider natriuretic peptide monitoring (BNP or NT-proBNP) to assess disease severity and prognosis 2
• Re-evaluate LVEF periodically, especially in patients with improvement 2

Common Pitfalls to Avoid

• Delaying quadruple therapy initiation in HFrEF patients
• Inadequate dose titration of medications
• Waiting for clinical deterioration before escalating therapy
• Discontinuing GDMT in patients with improved EF (HFimpEF) 2
• Using medications that worsen heart failure (thiazolidinediones, saxagliptin, NSAIDs) 1

By following this structured approach based on ejection fraction classification, clinicians can optimize heart failure management to reduce mortality, decrease hospitalizations, and improve quality of life for patients with heart failure.