What is the optimal management plan for a patient with heart failure with reduced ejection fraction (HFrEF) and improved left ventricular ejection fraction (LVEF) after coronary artery bypass grafting (CABG)?

Management of Heart Failure with Improved Ejection Fraction (HFimpEF) After CABG

Guideline-directed medical therapy (GDMT) should be continued in this patient with HFimpEF (LVEF improved from 30-35% to 35-40%) to prevent relapse of heart failure and left ventricular dysfunction, even though symptoms have improved. 1

Understanding the Patient's Current Status

This patient has:

• Recent CABG x3 (1 month ago)
• Initial LVEF of 30-35% (HFrEF)
• Current LVEF of 35-40% (HFimpEF)
• Severely dilated left atrium
• Mild valvular regurgitation (mitral, tricuspid, aortic)
• Currently asymptomatic

Management Algorithm for HFimpEF Post-CABG

1. Continue and Optimize GDMT

• Maintain all components of GDMT even though LVEF has improved and patient is asymptomatic 1
• The 2022 ACC/AHA/HFSA guidelines provide a Class 1, Level B-R recommendation for continuing GDMT in patients with HFimpEF to prevent relapse 1
• Studies show that withdrawal of HF medications in patients with improved LVEF results in relapse of cardiomyopathy in 40% of patients within 6 months 1

2. Components of GDMT to Maintain/Optimize

• Beta-blocker: Continue one of the three evidence-based beta-blockers (metoprolol succinate, bisoprolol, or carvedilol) 1, 2
• RAAS inhibitor: ACE inhibitor, ARB, or preferably ARNI (sacubitril/valsartan) 1, 2
• Mineralocorticoid receptor antagonist (MRA): Spironolactone or eplerenone 1, 2
• SGLT2 inhibitor: Dapagliflozin or empagliflozin regardless of diabetes status 1, 2
• Diuretics: Adjust as needed based on fluid status 1

3. Device Therapy Considerations

• ICD evaluation: Given the history of severely reduced EF (30-35%), evaluate for primary prevention ICD even though EF has improved to 35-40% 1
• The patient was initially prescribed a LifeVest but it was returned; this decision should be reassessed

4. Follow-up Monitoring

• Regular echocardiographic assessment: Continue to monitor LVEF trajectory 1
• Laboratory monitoring: Check renal function, electrolytes, and fasting lipids (already ordered) 2
• Clinical follow-up: Regular assessment of symptoms, medication tolerance, and optimization of GDMT doses 2

Important Considerations and Pitfalls

Medication Optimization

• Target doses matter: Aim for clinical trial-defined target doses of all GDMT components 1
• Uptitration strategy: Start at low doses and gradually uptitrate while monitoring blood pressure, heart rate, renal function, and electrolytes 1, 2
• Simultaneous initiation: Consider initiating multiple GDMT components simultaneously rather than sequentially 1

Common Pitfalls to Avoid

• Premature discontinuation: Avoid stopping GDMT even if the patient becomes asymptomatic 1
• Inadequate dose titration: Research shows that many patients post-CABG with HFrEF do not receive optimal GDMT dosing 3
• Underutilization of MRAs and SGLT2 inhibitors: These are often underutilized components of GDMT 4
• De-escalation during hospitalizations: Be cautious about reducing GDMT during non-cardiovascular hospitalizations, as this is associated with reduced survival 5

Special Considerations for Post-CABG Patients

• Activity restrictions: Appropriate to limit lifting (10 pounds for first 3 months, 25 pounds for months 3-6)
• Cardiac rehabilitation: Although the patient refused formal cardiac rehab, encourage structured physical activity 1
• Collaborative care: Consider a multidisciplinary approach involving cardiac surgery, heart failure cardiology, and pharmacy to optimize GDMT 3

Long-term Outcomes

• Patients with HFimpEF who continue GDMT have better long-term outcomes 1
• Quadruple therapy (beta-blocker, ACEi/ARB/ARNI, MRA, and SGLT2i) can reduce mortality by up to 73% over two years 2
• Patients with HFpEF after CABG still have higher long-term mortality than those with normal LV function, emphasizing the importance of continued GDMT 6

By following this comprehensive approach to GDMT in HFimpEF, this post-CABG patient has the best chance of maintaining improved cardiac function and preventing relapse of heart failure.