What is the management plan for a patient with heart failure with reduced ejection fraction (HFrEF), mild left ventricular dilation, and left ventricular ejection fraction of 40-45%?

Management of Heart Failure with Reduced Ejection Fraction (EF 40-45%)

For a patient with heart failure with reduced ejection fraction (HFrEF) with an ejection fraction of 40-45%, mild left ventricular dilation, and mild to moderate reduction in systolic function, quadruple therapy with a beta-blocker, ACE inhibitor/ARB/ARNI, mineralocorticoid receptor antagonist (MRA), and SGLT2 inhibitor should be initiated promptly to reduce mortality and improve quality of life. 1, 2

Initial Assessment and Classification

Based on the echocardiogram findings:

• LVEF 40-45% classifies as HFmrEF (Heart Failure with mildly reduced Ejection Fraction)
• Mild LV dilation with mild concentric LV hypertrophy
• Global Longitudinal Strain of -11.6% (indicating impaired contractility)
• Grade I diastolic dysfunction
• Conduction abnormality noted with septal motion

Pharmacological Management

First-Line Therapies (Start immediately)

1. SGLT2 inhibitor (Class 2a recommendation)

   • Dapagliflozin or empagliflozin regardless of diabetes status
   • Strongest recommendation for HFmrEF patients
   • Reduces HF hospitalizations and cardiovascular mortality 1

2. Beta-blocker (Class 2b recommendation)

   • Use evidence-based beta-blockers: carvedilol, metoprolol succinate, or bisoprolol 1, 3
   • Start at low dose and titrate gradually every 2-4 weeks as tolerated
   • Continue even if patient is hospitalized unless hemodynamically unstable 2

3. ACE inhibitor/ARB/ARNI (Class 2b recommendation)

   • Start with ACE inhibitor (e.g., lisinopril) 4
   • Consider switching to sacubitril/valsartan (ARNI) after clinical stability 1, 2
   • When switching from ACE inhibitor to ARNI, a mandatory 36-hour washout period is required 2

4. Mineralocorticoid Receptor Antagonist (MRA) (Class 2b recommendation)

   • Spironolactone or eplerenone 1
   • Monitor potassium and renal function closely
   • Particularly beneficial for patients with LVEF on the lower end of the spectrum 1

Diuretics for Symptom Management

• Loop diuretics (e.g., furosemide) as needed for fluid retention 1
• Adjust dose to maintain euvolemia while minimizing adverse effects 2

Medication Titration Strategy

1. Initiation Sequence:

   • Consider simultaneous or rapid sequence initiation of all four medication classes 2
   • For patients with hypotension or renal dysfunction, prioritize reaching target doses of beta-blockers and ACEI/ARB/ARNI before maximizing MRAs 2

2. Titration Schedule:

   • Titrate medications every 2-4 weeks as tolerated 2
   • Aim for target doses shown to be effective in clinical trials 1
   • Monitor renal function, electrolytes, and blood pressure during titration 1

Device Therapy Considerations

After 3 months of optimal medical therapy, if LVEF remains ≤35%:

1. Evaluate for ICD for primary prevention of sudden cardiac death 1, 2

2. Assess for Cardiac Resynchronization Therapy (CRT) if:

   • QRS ≥150 ms or
   • Left bundle branch block with QRS ≥130 ms 1, 2
   • Particularly relevant given the noted conduction abnormality on echocardiogram

Follow-up Plan

1. Short-term (2-4 weeks):

   • Monitor renal function, electrolytes, and blood pressure
   • Assess medication tolerance and side effects
   • Adjust diuretics based on volume status

2. Medium-term (3 months):

   • Reassess LVEF and symptoms
   • Make decision regarding device therapy
   • Optimize GDMT to target doses

3. Long-term:

   • Continue GDMT indefinitely, even if LVEF improves to >40% (HFimpEF) 2
   • Regular clinical and echocardiographic follow-up

Common Pitfalls to Avoid

1. Inadequate dose titration - Many patients remain on suboptimal doses of medications 2

2. Clinical inertia - Delaying addition of proven therapies or failing to titrate to target doses 2, 5

3. Premature discontinuation of GDMT during hospitalization or due to mild renal function changes or asymptomatic hypotension 2, 6

4. Underutilization of MRA therapy - Only 33% of eligible patients receive it despite clear mortality benefit 2, 7

5. Failure to continue GDMT if EF improves (HFimpEF) can lead to relapse 2

6. Sequential rather than simultaneous initiation of medications can delay achieving optimal therapy 8

By implementing this comprehensive approach to HFrEF management with prompt initiation of all four pillars of therapy, mortality can be reduced by up to 73% over two years with significant improvements in quality of life 2. Early referral to a heart failure specialist should be considered to optimize therapy and evaluate for advanced treatment options if needed.