Can any heart failure medications be stopped in a patient with improved ejection fraction (EF) on metoprolol succinate, sacubitril/valsartan (Entresto), spironolactone (Aldactone), and dapagliflozin (Farxiga)?

Management of Heart Failure Medications in a Patient with Improved Ejection Fraction

The most appropriate recommendation for this patient is to continue the current medication therapy despite the improvement in ejection fraction from 35% to 56%. 1

Rationale for Continuing Current Therapy

Understanding Heart Failure with Improved Ejection Fraction (HFimpEF)

• This 62-year-old male has HFimpEF, having improved from an EF of 35% to 56% over 2 years
• The improvement in EF is likely due to the effectiveness of his current guideline-directed medical therapy (GDMT)
• Despite EF normalization, the underlying pathophysiology of heart failure persists

Current Medication Regimen Analysis

1. Metoprolol succinate 50 mg daily

   • Beta-blockers are cornerstone therapy for HF that prevent disease progression and reduce mortality
   • Abrupt discontinuation can lead to "rebound" effects including increased risk of myocardial ischemia, infarction, and arrhythmias 1

2. Sacubitril/valsartan 97/103 mg twice daily

   • This patient is on the target dose shown to improve outcomes in HF
   • Associated with reduced hospitalization rates and improved symptoms even within the first 4 months of treatment 2
   • Has potential antiarrhythmic properties that may contribute to reduced risk of sudden cardiac death 3

3. Spironolactone 25 mg daily

   • The patient is on the target dose for mineralocorticoid receptor antagonist therapy
   • Continues to provide neurohormonal modulation even after EF improvement

4. Dapagliflozin 10 mg daily

   • SGLT2 inhibitors reduce mortality and hospitalization in heart failure patients 4
   • Provides cardiorenal protection beyond EF improvement

Evidence Supporting Continuation of Therapy

The framework proposed in the European Journal of Heart Failure (2020) emphasizes maintaining trial-based strategies that have demonstrated survival benefits (Status I), which includes target doses of these medications 1. Discontinuation would move the patient to Status III, which is not recommended.

The patient is clinically stable with:

• Well-controlled blood pressure (110/70 mmHg)
• Appropriate heart rate (60 beats/min)
• Normal laboratory values
• Good medication tolerance
• Insurance coverage for medications

Risks of Medication Discontinuation

Discontinuing any component of this regimen could lead to:

• Recurrence of heart failure symptoms
• Decline in ejection fraction
• Increased risk of hospitalization
• Increased mortality risk
• Loss of cardiorenal protection

Potential Pitfalls and Caveats

1. Misinterpreting improved EF as "cured" heart failure

   • HFimpEF is not the same as absence of heart disease
   • Underlying structural and neurohormonal abnormalities persist

2. Focusing solely on ejection fraction

   • EF is only one parameter of cardiac function
   • Diastolic dysfunction, arrhythmia risk, and neurohormonal activation may persist despite improved EF

3. Medication discontinuation considerations

   • If medication changes become necessary due to side effects:
     • Never stop beta-blockers abruptly (risk of rebound effects) 1
     • Monitor for worsening symptoms if any medication adjustments are made
     • Consider dose reduction before complete discontinuation

Monitoring Recommendations

• Continue regular follow-up with cardiology
• Periodic reassessment of ejection fraction (every 6-12 months)
• Regular monitoring of renal function and electrolytes
• Symptom surveillance for any signs of heart failure recurrence
• Daily weight monitoring to detect early fluid retention

In conclusion, despite the improved ejection fraction, the current evidence strongly supports continuing all components of this patient's heart failure medication regimen to maintain the clinical improvement and prevent disease progression.