From the Guidelines
For an 81-year-old patient with left ventricular ejection fraction (LVEF) of 40-45%, atrial fibrillation, and impaired left ventricular function, currently on ramipril and bisoprolol at submaximal doses, I recommend optimizing his current medications and considering additional therapies, prioritizing the most recent and highest quality study available 1.
Current Medication Optimization
First, gradually uptitrate his ramipril and bisoprolol to target doses as tolerated, monitoring blood pressure, heart rate, and renal function. The 2022 AHA/ACC/HFSA guideline for the management of heart failure recommends target doses for these medications, with ramipril targeting 10 mg once daily and bisoprolol targeting 10 mg once daily 1.
Additional Therapies
Add spironolactone 25mg daily if his eGFR is >30 ml/min and potassium is <5.0 mmol/L, as recommended for patients with heart failure with reduced ejection fraction (HFrEF) and LVEF ≤35% or following an acute MI with LVEF ≤40% and symptoms of HF or DM 1. However, given the patient's LVEF is between 40-45%, careful consideration and monitoring are necessary.
Atrial Fibrillation Management
For his atrial fibrillation, ensure appropriate anticoagulation with a direct oral anticoagulant (preferred) or warfarin based on his CHA₂DS₂-VASc score, as recommended for patients with chronic HF and permanent/persistent/paroxysmal AF with an additional risk factor for cardioembolic stroke 1. Rate control for atrial fibrillation should target a resting heart rate <110 bpm, with a beta blocker or nondihydropyridine calcium channel antagonist recommended for persistent or permanent AF in patients with HFpEF or HFrEF 1.
Considerations for Mortality Benefit
Consider adding a sodium-glucose cotransporter-2 (SGLT2) inhibitor like dapagliflozin 10mg daily, which provides mortality benefit in heart failure regardless of diabetes status, as per the most recent guidelines and studies 1.
Monitoring and Adjustments
Given his age, carefully monitor for side effects including orthostatic hypotension, electrolyte abnormalities, and renal function changes with each medication adjustment. These recommendations aim to reduce mortality, prevent heart failure hospitalizations, and manage his atrial fibrillation while considering his age-related vulnerabilities.
From the Research
Additional Management for Heart Failure
The patient has a left ventricular ejection fraction (LVEF) of 40-45%, atrial fibrillation, and impaired left ventricular function, and is currently on ramipril and bisoprolol at submaximal doses.
- The use of bisoprolol in combination with ACE inhibitors, such as ramipril, has been shown to improve survival in patients with stable chronic heart failure and reduce the need for hospitalization 2.
- Up-titration of ACE inhibitors, such as ramipril, to the maximum tolerated dose is recommended, as it has been associated with improved outcomes in patients with heart failure 3.
- Switching from ramipril to sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor (ARNI), may be considered, as it has been shown to favorably alter electrocardiographic indices of ventricular repolarization and reduce symptoms of heart failure 4.
- The addition of sacubitril/valsartan to the treatment regimen may also be beneficial, as it has been shown to reduce hospitalizations, cardiovascular and all-cause mortality in patients with ambulatory heart failure and reduced ejection fraction (HFrEF) 5.
- The patient's ability to tolerate the maximum dose of sacubitril/valsartan may depend on factors such as age, sex, body mass index, chronic kidney disease, and baseline tolerability of ACE inhibitors 5.
Key Considerations
- The patient's atrial fibrillation and impaired left ventricular function should be taken into account when considering additional management strategies.
- The use of beta-blockers, such as bisoprolol, in combination with ACE inhibitors and ARNI may be beneficial in reducing mortality and morbidity in patients with heart failure 2, 6.
- Regular monitoring of the patient's condition, including electrocardiographic indices and biomarkers such as NT-proBNP, may be necessary to assess the effectiveness of the treatment regimen and make adjustments as needed 4.