What are the management options for a patient with severely impaired left ventricular function, specifically a left ventricular ejection fraction (LVEF) of 15%?

From the Guidelines

A patient with an ejection fraction of 15% requires immediate comprehensive management for severe heart failure, prioritizing guideline-directed medical therapy to reduce morbidity, mortality, and improve quality of life. The management options should include an ACE inhibitor (e.g., lisinopril 2.5-5mg daily) or ARB if ACE inhibitor intolerant, a beta-blocker (e.g., carvedilol 3.125mg twice daily, titrated slowly), and an aldosterone antagonist (e.g., spironolactone 25mg daily) as recommended by the 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1.

Some key points to consider in the management of this patient include:

• The use of ACE inhibitors, beta-blockers, and MRAs is recommended in patients with HF with systolic dysfunction (LVEF ≤35–40%) to reduce total mortality and sudden cardiac death 1
• Diuretics (e.g., furosemide 20-40mg daily) should be used for volume management, as indicated by the 2009 ACC/AHA guidelines for the diagnosis and management of heart failure in adults 1
• Consideration of referral for an implantable cardioverter-defibrillator for primary prevention of sudden cardiac death, as recommended by the 2009 ACC/AHA guidelines for the diagnosis and management of heart failure in adults 1
• Hospitalization may be necessary for initial stabilization, and advanced therapies including left ventricular assist device or heart transplantation evaluation should be considered for appropriate candidates

The goal of treatment is to improve symptoms, reduce morbidity and mortality, and enhance quality of life. The most effective approach is to start with guideline-directed medical therapy, including an ACE inhibitor, beta-blocker, and aldosterone antagonist, and then consider additional therapies such as diuretics, implantable cardioverter-defibrillators, and advanced heart failure therapies as needed. Monitoring of renal function, electrolytes, and blood pressure is crucial during medication initiation and titration.

From the FDA Drug Label

Sacubitril and valsartan tablets are indicated to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure and reduced ejection fraction. Left ventricular ejection fraction (LVEF) is a variable measure, so use clinical judgment in deciding whom to treat [see Clinical Studies (14.1)].

The management options for a patient with severely impaired left ventricular function, specifically a left ventricular ejection fraction (LVEF) of 15%, may include sacubitril and valsartan tablets to reduce the risk of cardiovascular death and hospitalization for heart failure.

• The recommended starting dose of sacubitril and valsartan tablet is 49/51 mg orally twice-daily.
• The dose can be doubled after 2 to 4 weeks to the target maintenance dose of 97/103 mg twice daily, as tolerated by the patient 2.

From the Research

Management Options for Severely Impaired Left Ventricular Function

The management of a patient with severely impaired left ventricular function, specifically a left ventricular ejection fraction (LVEF) of 15%, involves a comprehensive approach to reduce symptoms, improve quality of life, and decrease the risk of mortality and hospitalization.

• Guideline-Directed Medical Therapy (GDMT): The foundation of treatment for heart failure with reduced ejection fraction (HFrEF) includes the use of quadruple therapy consisting of Angiotensin receptor blocker/neprilysin inhibitors, evidence-based beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors 3.
• Device Therapies: Certain patients may be candidates for device therapies such as implanted cardioverter defibrillators, cardiac resynchronization therapy, and trans catheter mitral valve repair 3.
• Uptitration of Medications: Uptitration of GDMT medications, including beta blockers, ACE inhibitors/Angiotensin/ARNI, and Mineralcorticoid receptor antagonists, can lead to an improvement in left ventricular ejection fraction (LVEF) and a reduction in the need for implantable cardioverter defibrillator (ICD) implantation 4.
• Protection with a Wearable Cardioverter Defibrillator (WCD): Patients with newly diagnosed cardiomyopathy and an EF ≤ 35% can be protected by a WCD while undergoing GDMT, allowing for the detection and termination of ventricular arrhythmias 4.
• Role of Other Medications: Other medications such as intravenous iron, ivabradine, hydralazine/nitrates, and vericiguat may also have a role in the management of certain subgroups of HFrEF patients 3.
• Importance of Guideline-Directed Prescribing Patterns: Heart failure hospitalization (HFH) represents an opportunity to titrate GDMT among patients with HFrEF, and de-escalation/discontinuation of GDMT after HFH is associated with an increased risk of all-cause mortality 5.

Considerations for Specific Patient Groups

• Patients with Reduced Ejection Fraction: Angiotensin-neprilysin inhibition compared to angiotensin inhibition has been shown to decrease sudden cardiac death in patients with reduced ejection fraction heart failure (rEFHF) 6.
• Patients with Hypertensive Heart Failure: The principal drug treatment of heart failure appears to be the same regardless of LVEF, with a focus on treating symptoms, signs, severity, and concomitant diseases and conditions 7.